


LIBRARY OF CONGRESS, 

Chap...A>„^. Copyright No. 

ShelfJEfii 

LS^ (o 



UNITED STATES OF AMERICA. 



^. 




Case of Xanthelasma. 



THE 



READY-REFERENCE HANDBOOK 



or 



DISEASES OE THE SKIN. 



BY 

GEOEGE THOMAS JACKSON, M.D. (Col.), 

*\ 

PROFESSOR OF DERMATOLOGY IN THE WOMAN'S MEDICAL COLLEGE OF THE NEW YORK INFIRMARY 
AND IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF VERMONT ; CHIEF OF CLINIC 
AND INSTRUCTOR IN DERMATOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS, 
NEW YORK ; CONSULTING DERMATOLOGIST TO THE PRESBYTERIAN HOS- 
PITAL, NEW YORK, AND TO THE NEW YORK INFIRMARY FOR 
WOMEN AND CHILDREN J MEMBER OF THE AMERICAN 
DERMATOLOGICAL ASSOCIATION AND OF THE 
NEW YORK DERMATOLOGICAL SOCIETY. 



WITH SIXTY-NINE ILLUSTRATIONS. 



SECOND EDITION, REVISED AND ENLARGED. 




AUG 8 18S* 



4*ttV{ 



-sr- 



LEA BKOTHEKS & CO., 

NEW YORK AND PHILADELPHIA. 

1896. 






Entered according to the Act of Congress, in the year 1896, by 

LEA BROTHERS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



DOBNAN, PRINTER. 



s 



PREFACE TO SECOND EDITION. 



In the preparation of the second edition of this book 
the first edition has been entirely revised so as to bring 
the matter down to date, and new sections have been added 
upon Acromegaly, Actinomycosis, Angioma serpiginosum, 
Baelzer's disease, Cheilitis glandularis, Clavus syphiliti- 
cus, Dermatitis repens, Multiple benign cystic epithelioma, 
Erythema induratum, Erythema elevatum diutinum, Feigned 
Eruptions, Hydroa vacciniforme or H. puerorurn, Osteosis 
cutis, Parakeratosis scutalaris et variegata, and Porokeratosis. 
Nineteen new illustrations have been inserted, which it is 
hoped will add to the value of the book. The text has 
likewise been considerably increased. 

I would again express my gratitude to my friend Pro- 
fessor George Henry Fox for his kindness in placing at 
my disposal a number of pictures from his admirable collec- 
tion of photographs, conspicuous for beauty and clearness. 

I can ask nothing better for this edition than the kindly 
acceptance accorded to its predecessor, and I venture to 
express the hope that it will prove useful to all those 
interested in the treatment of skin diseases. 

14 East Thirty-first Street, 

New York, June, 1896. 



vi PREFACE TO FIRST EDITION. 

from his admirable Illustrated Encyclopwdic Medical Dic- 
tionary, and for his courtesy in providing me with the pro- 
nunciation of many names in advance of their appearance 
in the same. 

I would also acknowledge my indebtedness to Dr. A. Rupp 
for special contributions upon eczema and furuncles of the 
ear, and to all those workers in dermatology from whose 
writings I have drawn freely so as to make this little book 
a presentation of modern dermatology. The admirable 
text-book of Dr. H. R. Crocker, of London, has been 
specially consulted by me, and has guided me through many 
a difficulty. 

Messrs. William Wood & Co. and D. Appleton & Co. 
have most courteously permitted me to make use of some 
papers of mine published in The Medical Record, The New 
York Medical Journal, and The Journal of Cutaneous 
and Genito- Urinary Diseases during the past years. 

14 East Thirty-first Street, 

New York, August, 1892. 



LIST OF ILLUSTRATIONS. 



FIG. 

Xanthoma .... 

1. Vertical section through the skin 

2. Hair in follicle 

3. Primary lesions of skin . 

4. Secondary lesions of skin 

5. Acne vulgaris 

6. Acne indurata of back . 

7. Fox's ring curette . 

8. Fox's acne lancet and curette 
9 Alopecia areata 

10 Angio-keratoma 

11. Trichorrhexis nodosa 

12. Atrophoderma pigmentosum 

13. Microsporon furfur 

14. Demodex folliculorum . 

15. Piffard's comedo-extractors 

16. Fox's comedo-scoop 

17. Dermatitis herpetiformis 

18. Bromide of potassium eruption in 

19. Dermatitis papillaris capillitii 

20. Dermatitis venenata 

21. Elephantiasis 

22 Epithelioma . 

23 Dermal curette 

24. Favus of hand 

25. Favus of hand 

26. Favus of knee 

27. Achorion schoenleinii 

28. Achorion schoenleinii in hair shaft 

29. Piffard's epilating forceps 

30. Multiple fibromata 



child 



PAGE 

frontispiece 
14 
19 
24 
24 
52 
55 
62 
63 
80 
86 
90 
94 
117 
122 
123 
123 
141 
147 
150 
153 
201 
207 
212 
239 
239 
240 
242 
243 
245 
250 



VI 11 



LIST OF ILLUSTRATIONS. 



FIG. 

31. Herpes facialis 

32. Hidrocystoma 

33. Ichthyosis 

34. Keloid . 

35. Tubercular and anaesthetic leprosy 

36. Leucoderma . 

37. Lichen ruber moniliformis 

38. Scarifying knife 

39. Lymphangioma 

40. Molluscum . 

41. Molluscum corpuscles . 

42. Nsevus lipomatodes 

43. Pediculus capillitii 

44. Pediculus corporis 

45. Pediculus pubis 

46. Ova of head louse 

47. Porokeratosis 

48. Psoriasis 

49. Psoriasis 

50. Rhinoscleroma 

51. Ehinophyma . 

52. Acarus scabiei 

53. Acarus scabiei 

54. Acarus scabiei 

55. Sebaceous cyst 
56 Scaling papular syphilide of palm 

57. Condylomata lata 

58. Annular tubercular syphilide 

59. Squamous serpiginous syphilide 

60. Gummata 

61. Hutchinson's teeth . 

62. Dactylitis 

63. Keyes' punch . 

64. Trichophytosis corporis 

65. Trichophytosis capitis 
6Q. Trichophytosis barbae 

67. Trichophyton fungus 

68. Tuberculosis verrucosa cutis 

69. Zoster of arm . 



PAGE 

264 
269 
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305 
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318 
336 
340 
346 
347 
356 
375 
375 
375 
376 
402 
413 
414 
433 
437 
449 
450 
451 
463 
490 
491 
495 
497 
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510 
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526 
529 
531 
534 
543 
565 



DISEASES OF THE SKIN. 



PAKT I. 

GENERAL CONSIDERATIONS. 

Anatomy and Physiology of the Skin. 

Before we enter upon the consideration of the separate 
diseases of the skin, it will be well for us to refresh our 
memory as to its anatomy. It is not my desire to give a 
complete and exhaustive chapter on this subject, but to 
draw attention to those properties of the cutaneous envelope 
that are of practical importance to us. For a more extended 
consideration of this subject, the student is referred to 
Unna's article in Ziemssens Encyclopcedia} and Part I. of 
Duhring's Cutaneous Medicine. 

The skin is made up of three distinct layers, namely : 1, 
the epidermis ; 2, the derma, also named the cutis vera or 
corium ; and, 3, the subcutaneous connective tissue. The 
appendages of the skin are the hair and the nails, the seba- 
ceous and the sweat glands. This complicated structure is 
supplied with bloodvessels, lymphatics, and nerves. 

Epidermis. The epidermis is composed of four layers, 
called strata, namely : 1, the stratum corneum ; 2, the stratum 
lucidum ; 3, the stratum granulosum ; and, 4, the stratum 
mucosum. Of these strata, the two that most concern us 
are the first and the last — that is, the stratum corneum and 
the stratum mucosum. The other layers of the skin may, 

1 Handbuch der Hautkrankkeiten, Bd. xiv. Ziemssen's Encyclopaedia. 

2 



14 



GENERAL CONSIDERATIONS. 



for our present purpose, be regarded as simply transition- 
layers through which an epithelial cell passes on its develop- 
mental way to become a fully formed and rightly compacted 



Fig. 1. 




Vertical section through the skin. (After Heitzmann.) Diagrammatic. 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 15 

corneous cell. Each of the four strata of the epidermis is 
divided again into layers, but these are of no practical im- 
portance. 

The stratum eorneum consists of a series of superimposed 
layers of flattened, elongated cells, that increase in flatness 
from below upward. The upper layers are called scales. 
The cells of each layer are united to each other so much 
closer than the layer itself is united to those above and 
below it, that when an effusion takes place into the stratum 
eorneum a layer of cells in the affected area is raised, and 
the fluid is found between two layers. The lamellated scal- 
ing met with in certain scaly diseases, such as dermatitis 
exfoliativa, in which great plates of scales are readily re- 
movable, is likewise due to this close relation between the 
cells of each layer. This stratum is largely a protective 
one, its compactness affording a fair degree of resistance to 
injury of the underlying, more succulent layers of the 
epidermis. 

The stratum mucosum is the deepest layer of the epider- 
mis, and is seated upon the papillary layer of the corium. 
It is composed of several layers of cells, but may be con- 
sidered to consist of two chief layers, namely, the columnar 
epithelium and the prickle cells. The columnar epithelium 
are arranged perpendicularly to the papillae of the corium, 
while the prickle cells, which are polygonal in shape with 
spherical nuclei and with little filaments running out from 
their sides toward the neighboring cells, are arranged in 
strata over them. As the stratum granulosum which lies 
above the stratum mucosum is approached, the prickle cells 
become flatter, and finally lie with their long axis parallel 
to the general surface. The stratum mucosum, also called 
the rete Malpighii, is the most important stratum of the epi- 
dermis, and the seat of that most common of all skin dis- 
eases, eczema. From its lower part it sends down projec- 
tions between the papillae of the corium, which are called 
inter-papillary projections. Most of the pigment of the 
skin is situated in the lower part of the stratum mucosum. 
As the upper part is approached, less and less pigment is 
found. The pigment itself is in the form of granules and of 



16 GENERAL CONSIDERATIONS. 

diffused coloring-matter. According to Unna, the pigment 
is found even in the upper part of this layer, while in path- 
ological conditions it may be located in the corium. 

From this arrangement of the cells of the epidermis it will 
be seen that nutrient fluids can readily work upward from 
below by means of the little channels formed by the inter- 
lacing of the filaments running between the cells. 

The epidermis has no bloodvessels. It receives its nutri- 
tion entirely from the corium. Though there are no true 
lymphatics in the epidermis, there are abundant lymph 
spaces between the cells that take their place. Nerves of 
the non-medullated variety have been traced between the 
cells of the epidermis, and have been described by some his- 
tologists as entering into the cells to end at the nucleus, 
though not to enter it. The final distribution of the nerves 
in the epidermis is not yet fully determined. 

Corium. The corium is composed of white fibrous and 
yellow connective tissue, disposed in horizontal bundles 
above and in oblique bundles below. It is a very dense 
and tough tissue, and is pierced in all directions to allow of 
the passage of bloodvessels, lymphatics, sweat ducts, and 
nerves, and affords lodgement for the hair follicles and seba- 
ceous glands. It contains a considerable amount of elastic 
fibres. The upper part has been named the pars papillaris, 
and the lower part the pars reticularis corii. From its 
upper part it sends off a vast number of projections called 
papilla?. These vary in length, being longest and most 
marked on the ends of the fingers and toes. The epidermis 
follows these projections, and dips down between them. 
They are readily seen as parallel markings on the ends of 
the fingers. Over most of the body surface the papillae are 
but slightly raised, and merely give a wavy appearance to 
the upper edge of the corium when viewed under the micro- 
scope. A fine basement-membrane separates the corium 
from the epidermis. This is regarded by some as a cement- 
substance. As we reach the lower part of the corium the 
bundles of fibres are less closely crowded together, and be- 
coming successively looser gradually pass over into the 

Subcutaneous connective tissue. This is a loose connec- 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 17 

tive tissue with larger or smaller spaces in it, which are filled 
with the adipose tissue. This consists of fat-cells collected 
into lobulated masses, that in some cases have about them 
a connective-tissue sheath. Each lobule is supplied with an 
afferent artery, a capillary plexus about it, and efferent 
veins. This part of the skin is called the panniculus adi- 
posus, and is found everywhere except in the skin of the 
penis, scrotum, labia minora, eyelids, pinna, and beneath 
the nails. It contributes to the roundness and beauty of 
the body, besides acting as a storehouse for fuel against 
such times as the body cannot gain its proper nutriment 
from food, as in fevers. It also gives lodgement to the coil 
or sweat glands, and aids in protecting the underlying parts 
from injury. The lower end of the deep hair follicles are 
also in this part of the skin. The subcutaneous tissue merges 
into the underlying fasciae of the muscles and the periosteum 
of the bones. 

Bloodvessels. The arteries which supply the skin come 
up from below to form a horizontal plexus in the subcutane- 
ous tissue from which the vessels proceed perpendicularly 
through the corium to form a second horizontal plexus just 
below the papillae. From the lower plexus small branches 
pass to the fat-cells, sweat glands, and, according to Unna, 
to the hair papillae. From the upper plexus branches are 
given off which enter the papillae of the skin. There are 
also branches to the hair follicles, sebaceous glands, and the 
tissue of the corium itself. Papillae that give lodgement to a 
tactile corpuscle have no arterial twig. The veins follow the 
same course as the arteries, but, of course, in the opposite 
direction. 

Lymphatics. Lymph-vessels are large in the subcutane- 
ous tissue, smaller in the upper part of the corium, and form 
plexuses. " Juice-spaces, " filled with lymph, are found 
abundantly in the epidermis and papillae, about the glands 
of the skin, and around the muscles of the skin and the con- 
nective-tissue bundles and fat-lobules. 

Nerves. The skin is provided with both medullated 
and non-medullated nerve-fibres and motor and vasomotor 
nerves. We have already learned that non-medullated 



18 GENERAL CONSIDERATIONS. 

nerve-fibres have been traced between the cells of the 
epidermis, some terminating at, if not in, the nuclei of 
the cells. It may be roughly stated that the nerves fol- 
low pretty much the same arrangement as the bloodvessels, 
forming a sort of plexus beneath the papillae and then giv- 
ing off branches to the vessels, to the tactile corpuscles, to 
the papillae, the hair follicles, the sebaceous and sweat glands, 
and the epidermis. 

The tactile corpuscles (corpuscles of Meissner) are located 
in the papillae. They are oval or round bodies, and their 
long axis runs longitudinally. Not more than one papilla 
in four is supplied with one of these corpuscles, even where 
they are most abundant — at the end of the index finger. 
They are composed, according to Unna, of large, flat con- 
nective-tissue cells which are placed one above the other 
like money-rolls, and take up between them the terminal 
branches of the medullated nerves, which on entering the 
bodies lose their medulla and finally end between the cells. 
The transversely striped appearance presented by the cor- 
puscles is due to the swollen lateral edges of the cells, and 
the band-like nerve-fibres that here and there appear upon 
the surface. 

. The corpuscles of Krause are located in the sensory 
mucous membranes. They are rounded in shape and bear 
a close resemblance to the Pacinian corpuscles in structure. 
The Pacinian corpuscles are located in the subcutaneous 
tissues, and also in connection with the sensitive nerves. 
They are oval in form, visible to the naked eye, and con- 
sist in a colossal swelling-out of the sheath of Schwann, 
forming a thick connective-tissue capsule surrounding a 
much smaller cylindrical cavity filled with granular, faintly 
filamentous cellular substance through the axis of which 
passes a sensitive nerve. As the latter enters the corpuscle 
it loses its medulla, and either terminates in the corpuscle 
or passes through it to enter one or more corpuscles. These 
corpuscles are most abundant in the fingers and toes, and 
the palms and soles. They are supposed to enable us to 
appreciate pressure or traction. 

Hair. The hair is an epidermic structure which grows 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 19 

from a nipple-shaped projection, the hair papilla, situated 
at the bottom of a deep, slender pocket or sac-like depres- 
sion in the skin which is called the hair follicle. Com- 

FlG. 2. 




Hair in follicle. (After Kaposi.) 

a. Follicle mouth, b. Neck. c. Arch of follicle, d. Outer, e. inner sheath 
of follicle. /. Hair papilla, m. Fat-cells, n. Erector pili muscle, ep. Epi- 
dermis, s. Mucous layer of epidermis, o. Skin papillae, t. Sebaceous glands. 
/. External, g. internal root sheath, h. Cortex of hair. k. Medullary canal. 
I. Hair root. 



mencing at the papilla it is bulb-shaped. This part is 
called the bulb and fits over the papilla like a cap. On 
leaving the papilla the body of the hair is first called the 



20 GENERAL CONSIDERATIONS. 

root, and then as it becomes narrower the shaft. The 
diameter of the shaft rapidly decreases until, leaving the 
skin, it terminates in the point. A fully formed hair is hol- 
low, its central cavity being called the medullary canal and 
filled with the medulla. This is composed of a column of 
cells arranged in layers, one layer being superimposed on 
another. The main substance of the hair is called the 
cortex, and consists of long spindle-shaped epithelial cells 
flattened out into fine bands and running in the long axis of 
the hair. This part of the hair gives it substance and 
strength, and in it is placed the pigment that determines 
the color of the hair. The outer layer of the hair is called 
the cuticle. It corresponds to the epidermis, and consists 
of flattened, non-nucleated, fully cornified cells which cover 
the hair like scales, and overlap each other like shingles. 

The hair follicle is located for the most part in the 
corium, but in some very strong hairs it reaches down into 
the subcutaneous tissue. It is always, excepting at the 
dorsal edge of the eyelids, placed at an angle to the skin, 
and is a permanent structure that is not removed when the 
hair is plucked. It is composed of three layers, which are 
derived from the corium as it dips down to form the follicle. 
Between the follicle and the hair we have the root sheath, 
which is derived from the epidermis. It is composed of two 
layers, which are called the external and internal root 
sheaths. The whole arrangement of the hair and its sheath 
may be graphically conceived by regarding the hair as a 
blunt needle pressed against the skin. The needle would 
form the hair, the epidermis would form the root sheath, and 
the corium would be to the outside of all and form the hair 
follicle. 

Hair is found on all parts of the body excepting the 
palms and soles, the terminal phalanges of the fingers and 
toes, the glans penis, prepuce, labia minora, and the ver- 
milion border of the lips. In form it is flattened or 
rounded, straight or curled. There are three main varieties 
of hair: 1. Long, soft hair, as of the head and beard. 

2. Short, stiff hair, as of the eyebrows and lashes ; and, 

3, Lanugo, or soft, downy, colorless hair that is scattered 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 21 

all over the surface of the body where the other varieties 
are not. 

Nails. The nails, like the hair, are epidermic structures. 
They are placed on the extensor surfaces of the terminal 
phalanges of the fingers and toes. Their proximal end is 
called the root, under which is the matrix, from which they 
grow. On the way to their distal end they pass over the 
nail bed. This is separated from the matrix by a more or 
less convex and apparent line called the lunula. At their 
posterior and lateral margins they are imbedded in a fold of 
skin that is called the nail fold. At their distal extremity 
they are separated from the end of the finger or toe. They 
are formed by the matrix, but in passing over the bed they 
receive a certain amount of nourishment from it, and their 
cells become rapidly cornified. They are slightly curved from 
side to side, being convex above and concave below, and are 
marked with fine lines. The flesh beneath the nail is the 
same as the skin in general, though without subcutaneous 
tissue. The nail takes the place of the corneous and granular 
layers of the skin. 

Sebaceous Glands. (Fig. 1.) These glands are of the 
racemose variety, and are closely related to the hairs, from 
two to six being attached to each hair, emptying by their 
ducts into the upper third of the follicle. Each gland is 
composed of a number of acini that empty by a common duct. 
They are composed of a delicate structureless capsule, the 
membrana propria, which continues along the duct to merge 
into the hair follicles. This is lined with large, though short, 
cubical or cylindrical epithelial cells arranged in one or two 
rows. These are continuous through the duct with the cylin- 
drical cells of the outer root sheath of the hair and of the skin. 
The interior of the glands is filled with fatty secretion. 
Around the gland passes the external layer of the hair folli- 
cle. These glands occur also on the vermilion border of the 
lips, the labia minora, and the glans penis and prepuce, 
though in these locations there are no hairs. 

The function of the sebaceous glands is to oil the hair and 
skin, thus rendering them soft and supple, and giving lustre 
to the hair. This oily secretion is produced by the cells, 

2* 



22 GENERAL CONSIDERATIONS. 

which, as they reach the central part of the acini, undergo 
fatty degeneration. The glands are largest in the nose, 
cheeks, scrotum, mons veneris, labia, and about the anus. 

Sweat Glands. (Fig. 1.) The sweat glands are simple 
coil glands that are located in the lower part of the corium 
and in the subcutaneous tissue. From here their ducts 
ascend through the corium in a straight or wavy line to the 
mterpapillary spaces, where they enter the epidermis, and 
then the sweat makes its way to the surface of the skin be- 
tween the epithelial cells. The cells lining the coil are sim- 
ple cubical epithelial cells. These are seated upon muscular 
fibres ; and a connective tissue, the membrana propria, comes 
outside of all. The duct is made up of pavement-epithelium 
upon the membrana propria. When the epidermis is reached 
the membrana propria is lost, and the further track of the 
duct seems to be made by the sweat working its own channel 
up between the epidermic cells. Unna teaches that the sweat 
produced by the coil glands is mixed with other elements 
while passing through the epidermis, so that the secretion 
that appears at the sweat pores is not the same as that which 
leaves the coils. He further teaches that the office of the 
coil glands is not to produce sweat, but to oil the skin. This 
theory still needs confirmation before it can be accepted as 
absolutely true. His arguments have considerable weight, 
but space will not allow of their statement here. It has long 
been known that there was a certain amount of oil in the sweat. 
Sweat glands are most numerous in the palms and soles. 

Muscles. The skin is provided with muscles, both of 
the striated and unstriated variety. The striated muscles 
are found in the face and nose. The majority of the mus- 
cles of the skin are involuntarv muscles. In the scrotum 
they run parallel with the raphe. On the penis and about 
the nipple their direction is circular. The arrectores pilorum 
muscles are found all over the body, running in a more or 
less oblique direction from the bottom of several papillae 
down and around a sebaceous gland to be attached to the 
bottom of a hair follicle. By contracting they raise the 
hairs to a perpendicular position, and aid in pressing out 
the contents of the sebaceous glands. 



DIAGNOSIS. 23 

Diagnosis. 

The Lesions of the Skin. There once was a time 
when skin diseases were classified by their lesions. A 
knowledge of the lesions of the skin is no longer necessary 
for purposes of classification, but it is essential to the under- 
standing of dermatological literature. It is well to become 
familiar with them as soon as possible, for, though after one 
has once become versed in dermatology, he probably will not 
stop to think whether a given disease is papular, vesicular, 
pustular, or not, but will name it from its physiognomy ; 
nevertheless, in doubtful cases the recognition of the most 
prominent lesion will sometimes aid in diagnosis. Further- 
more, time will be saved and clearness gained by using the 
proper phraseology in describing a case. 

We speak of primary and secondary lesions of the skin. 
By the first of these terms we mean the form assumed by the 
efflorescence at its first appearance. By the second of these 
terms we mean the subsequent changes the primary lesion 
undergoes of itself, or as the result of extraneous causes act- 
ing upon it. In running its course, whether influenced by 
treatment or not, almost every disease of the skin exhibits 
more than one lesion, and we can only speak of it as a mac- 
ular, papular, or other disease from its most prominent and 
characteristic lesion. 

The primary lesions of the skin are the macule, the papule, 
the tubercle, the vesicle, the pustule, the bulla, the wheal, 
and the tumor. The secondary lesions of the skin are the 
crust, the scale, the excoriation, the fissure, the ulcer, and 
the cicatrix. These may be graphicallly represented, follow- 
ing Piffard. 1 

Primary Lesions. A macule is a spot or stain of the 
skin which is not raised above its surface. It may be of 
any size from a pin-point to the palm of the hand, or larger; 
but these large-sized and diffused non-elevated lesions are 
usually spoken of as patches. It is usually round in shape, 
but may be of any shape. It may be white, red, brown, 

1 Cutaneous Memoranda. Wood, N. Y., 1885. 



24 GENERAL CONSIDERATIONS. 

black, blue, pink, or yellow, according to its cause. It may 
be due to hyperemia, as in erythema simplex ; to a change 
in the pigmentation of the skin, as in lentigo and chloasma, 
where there is increase of pigmentation, or in vitiligo, where 
there is decrease of pigmentation ; to a hemorrhage into the 
skin, as in purpura ; to a development of bloodvessels in 
the skin, as in nsevus vascularis and telangiectasis ; to a 
parasitic growth in the skin, as in chromophytosis ; or to a 
change in the consistency of the skin, as in morphcea and 
xanthoma. 



Fig. 3. 


LESIONS OF THE SKIN. 


Fig. 4. 


Primary. 




Secondary. 



Macule — — — — 

Crust 



Papule 

Scale 



Tubercle 

Excoriation 




A 



Vesicle 

Fissure 

Pustule 

Ulcer 



Bulla 

Cicatrix 




"V 




Wheal 



Tumor 




The macule may be evanescent or permanent ; may re- 
main as a macule during its existence, or may give place to 
a papule, vesicle, or pustule. It is the simplest of all the 
lesions of the skin, and is met with as a primary lesion of 
many of its diseases. 

The principal macular diseases are chloasma, erythema 



DIAGNOSIS. 25 

simplex, lentigo, morphoea, nsevus simplex and spilus, pur- 
pura, scleroderma, chromophytosis, vitiligo, xanthoma, and 
melasma. 

A papule is a circumscribed, solid elevation of the skin. 
In size it varies from that of a pin-point to that of a split- 
pea. It may be of different colors, but is usually some shade 
of red. It is soft or firm to the touch. In form it may be 
acuminated, rounded, flattened, umbilicated, or angular. It 
may be due to inflammation, as in eczema ; to a hypertrophy 
of normal structures, as in verruca ; to the heaping up of 
epidermic cells about a hair follicle, as in keratosis pilaris ; 
or to the retention of sebaceous matter in a follicle, as in 
comedo and milium. 

The papule may remain as such throughout its course, 
and finally be absorbed ; or it may change into a vesicle or 
pustule ; or it may soften and break down. 

Papular diseases have received the name of lichenoid dis- 
eases, and at one time we had a goodly number of lichens. 
Most of these have now been placed under other headings, 
as it is recognized that they are but single manifestations of 
other diseases. Papular diseases are apt to be scaly and 
itchy. 

The principal papular diseases are : lichen tropicus, lichen 
ruber acuminatus and planus, lichen scrofulosorum, lichen 
pilaris or keratosis pilaris, lichen urticatus or papular urti- 
caria, acne, comedo, milium, prurigo, and psoriasis. Like 
the macule, the papule is found in many diseases that cannot 
be classed as papular. 

A tubercle may be thought of as a large papule. Like 
it, it is a circumscribed solid elevation of the skin. Indeed, 
the difference between a papule and a tubercle is mainly 
arbitrary and for convenience. Thus, we speak of a solid 
lesion up to the size of a split-pea as a papule, while above 
that it is spoken of as a tubercle. Quite commonly, when 
a lesion is larger than a cherry it is spoken of as a node. 
Auspitz 1 makes the distinction between a papule and tubercle 
on more scientific grounds, and regards a tubercle as a cell- 

1 Ziemssen's Handbuch der Hautkrankheiten. 



26 GENERAL CONSIDERATIONS. 

infiltration into the corium. A tubercle is not only larger 
than a papule, but it extends deeper into the skin. In form 
and color a tubercle corresponds to a papule. 

Tubercles may be absorbed and disappear and leave no 
trace ; or they may break down and ulcerate and leave scars, 
as in syphilis ; or they may remain unchanged for an indefi- 
nite period, as in molluscum. 

The principal tubercular diseases are : carbuncle, epithe- 
lioma, keloid, lupus vulgaris, molluscum, rhinoscleroma, and 
xanthoma. Tubercles form a very prominent symptom in 
leprosy, syphilis, and erythema multiforme. Of course, 
tubercular used in this sense has nothing to do with true 
tuberculous processes. 

A vesicle is a circumscribed elevation of the epidermis 
that contains fluid, generally serous. In size it varies from 
a pinhead to a split-pea. Its color is crystalline when only 
serum is present, more or less opaque and yellowish when 
the serum is mixed with pus, and of a reddish hue when 
blood is effused into it. It may be pointed, rounded, flat- 
tened, or umbilicated. Vesicles are in most cases due to 
inflammation, as in eczema. They may be due to simple 
serous effusion, as in erythema; or to the retention of sweat, 
as in sudamina. They have around them, in many cases, a 
red halo. As a rule, vesicles are superficial elevations of the 
epidermis, and readily rupture and pour out their contents 
upon the skin, forming a yellowish crust. They may be 
below the mucous layer of the skin. They may remain as 
vesicles, and dry up, their contents being absorbed ; or they 
may become changed into pustules. 

The principal vesicular diseases are : eczema, herpes, suda- 
mina, dysidrosis, dermatitis venenata, zoster, impetigo con- 
tagiosa, and varicella. 

A pustule is a circumscribed elevation of the epidermis 
containing pus. In size and shape it corresponds to the 
vesicle. Its color is yellow and opaque; or brown or 
reddish if there is an admixture of blood with the pus. It 
either originates as a pustule or develops from a vesicle or 
papule. As a rule, pustules are inflammatory, and when 
they appear as a general eruption, as in syphilis, they indi- 



DIAGNOSIS. 27 

cate a strumous or broken-down condition. Around each 
pustule there is very commonly a well-marked inflammatory 
areola. 

Pustules are prone to break down and discharge their 
contents upon the skin, forming a greenish or blackish crust. 
If located deep in the skin, they may leave scars. 

The principal pustular diseases are acne vulgaris, im- 
petigo, ecthyma, sycosis, and furunculosis. 

A bulla may be considered as a large vesicle or pustule. 
It is of irregular oval shape or umbilicated. It may be as 
large as a split-pea, or reach the size of a goose-egg. It 
rises up from the skin with a slight areola or with none at 
all. It is either fully distended or flaccid, and does not 
rupture readily. It may be a bulla from the beginning, as 
we see in pemphigus, or it may be formed by the coa- 
lescence of two or more vesicles ; or it may form above an 
erythematous lesion, as in erythema multiforme. Its contents 
are usually serous, but this may give place in time to pus. 

The only purely bullous disease is pemphigus, but bullae 
are met with in dermatitis, dermatitis herpetiformis, erysip- 
elas, syphilis, leprosy, and erythema multiforme. 

A wheal is an evanescent round, oval, or elongated flat 
elevation of the skin, of a pinkish or white color, which is 
more or less firm to the touch. It is surrounded by a red 
halo. It may be as small as a pea or as large as the palm 
of the hand. Wheals appear suddenly, and disappear within 
a few hours. They are due to a spasm of the capillaries and 
an effusion of serum into the meshes of the skin, the raised 
part being the site of the effused fluid, and the halo the con- 
gested vessels in the neighborhood. The disease in which 
wheals are met with is urticaria. They can also be produced 
by contact with the stinging-nettle, or by sharp traumatism 
on skins predisposed to urticaria. 

A tumor is a new growth in the skin which projects more 
or less above its surface and dips down into the subcutane- 
ous tissue. It may be pedunculated. It is rather a surgical 
than a dermatological lesion. Epithelioma, fibroma, and 
sarcoma are types of tumors. They are met with also in 
syphilis and scrofula. 



28 GENERAL CONSIDERATIONS. 

Secondary Lesions. The secondary lesions of the skin 
require a much less extended description. The main dis- 
tinction to be retained in the student's mind is that between 
a crust and a scale. This can be readily done if it is re- 
membered that a crust is formed by the drying of some 
secretion or exudation upon the skin ; while > scale is a dry, 
laminated mass of epidermis which has separated from the 
tissues below, the product of imperfect or perverted nutri- 
tion. Thus, in vesicular eczema when the exudation dries 
on the skin we have a yellowish crust ; while in squamous 
eczema we have thin scales, the horny layer of the skin not 
being perfectly produced. Crusts are light-yellow to dark- 
green or black in color, the latter indicating an admixture 
of blood. Scales are whitish, grayish, yellowish, or dirty 
yellow. 

Crusts are especially characteristic of ecthyma, some forms 
of eczema, impetigo, and seborrhcea. 

Scales are specially abundant in dermatitis exfoliativa, 
pityriasis simplex, pityriasis rubra pilaris, psoriasis, ichthy- 
osis, and some of the lichens. 

Excoriations are familiar as scratch-marks. They are 
superficial denudations of the skin. They are of value as 
a sign of itching, as scratching is their chief though not sole 
cause. They frequently are followed by pigmentation, if 
the irritation causing the scratching is long-continued. 

Fissures are cracks in the epidermis extending down to 
the corium. They are usually located in the folds of the 
skin, as over the joints. They occur in diseases attended 
by infiltration and thickening of the skin by which its 
elasticity is interfered with, and are especially seen in 
eczema and syphilis. They often bleed, and sometimes 
are very painful. 

Ulcers are irregularly shaped and sized losses of sub- 
stance. They may be quite small, or of very large size. 
They may be shallow, deep, excavated, or scooped out. 
Their edges may be undermined, as in scrofula ; everted, 
as in epithelioma; or sharp-cut, " punched out," as in 
syphilis. Their secretion may be scanty or abundant. They 
result either from some previous lesion or from injury. They 



DIAGNOSIS. 29 

occur in epithelioma, sarcoma, carbuncle, furuncle, chancre, 
chancroid, lupus vulgaris, syphilis, scrofula, varicose eczema, 
ecthyma, and sometimes after zoster, dermatitis, and some 
pustular eruptions. They always heal with a cicatrix, leav- 
ing a scar. 

Cicatrices, or scars, represent the effort of Nature to heal 
a damage to the skin by means of connective tissue. They 
occur only when the papillary layer of the skin or the parts 
beneath are destroyed. They may be depressed, as in small- 
pox ; raised and puckered, as in lupus ; smooth and white, 
as in syphilis. 

Other Elements of Diagnosis. Having mastered the 
lesions of the skin, we are now prepared to study the other 
elements of diagnosis. We must observe the location, dis- 
tribution, and configuration of the eruption, and note its 
color and whether or not it itches. When we have done all 
this, and have come to a probable conclusion as to the disease 
before us, then is the proper time to ask the patient a few 
questions as to his sensations and the duration of the attack. 
In a few cases of doubtful diagnosis the microscope will aid us. 

Location. Upon the face we meet with acne, comedo, 
chloasma, erythematous eczema, epithelioma, herpes febrilis, 
lupus vulgaris and erythematosus, milium, rosacea, sycosis, 
and xanthoma. 

An eruption occupying the middle third of the face, fore- 
head, nose, and chin is in all probability rosacea. 

An eruption occupying the bearded portion of the face, 
above a line drawn from the angle of the mouth to the angle 
of the jaw, is probably sycosis. Should it occupy the 
bearded portion of the face below that line it is probably 
trichophytosis barbae. 

If a scaly patch is found in front of the ears, it should put 
us on the lookout for psoriasis, which will often be found 
elsewhere on the body. This point may be useful in the 
diagnosis of a doubtful case. If a raw, or cracked, or scaly 
place is found behind the ears, it points to eczema. 

Upon the scalp we meet w T ith pediculosis capitis, sebor- 
rhea, trichophytosis, favus, alopecia, and alopecia areata. 



30 GENERAL CONSIDERATIONS. 

If we find a patch of pustular eczema upon the back of 
the head and about the nape the neck, the case is probably 
one of pediculosis ; and if we look for the nits, we shall find 
them either at the site of the eruption or over the parietal 
region. 

The chest is the favorite location for chromophytosis and 
keloid. 

Upon the back we meet with acne, carbuncle, and the 
scratch-marks due to the irritation from pediculi. If you 
find long, parallel scratch-marks over the shoulder-blades, it 
is quite good evidence of pediculi in the clothing. 

The extensor surfaces of the forearms and wrists are the 
favorite sites of erythema multiforme. The elbow is affected 
with psoriasis ; while the flexor surfaces give lodgement to 
lichen planus and scabies, and the bend of the elbow to 
eczema. 

Upon the legs purpura, erythema exudativum, and ele- 
phantiasis are apt to occur. 

A general eruption is either one of the exanthematous 
fevers, or syphilis, psoriasis, dermatitis exfoliativa, pityriasis 
rubra pilaris, lichen ruber acuminatus, lichen planus, eczema, 
erythema, scabies, or ichthyosis. 

Of these, syphilis is most marked on the sides of the chest 
and abdomen, and upon the face along the margin of the 
hair. It may also be given as a general rule, to which there 
are many exceptions, that syphilis occupies the flexor sur- 
faces of the arms and the anterior plane of the trunk, while 
psoriasis is found most markedly upon the extensor surfaces 
and the posterior plane of the trunk. 

Configukation. Certain diseases assume certain con- 
figurations, which, if noted, will sometimes assist in diagnosis. 
Thus we have 

The circular outline and scalloped border of syphilis. 

The round and bald patch of trichophytosis and alopecia 
areata. 

The map-like border of psoriasis. 

The oval or egg-shaped lesions of erythema nodosum and 
the gumma of syphilis. 

The angular papules of lichen planus. 



DIAGNOSIS. 31 

The annular arrangement in herpes iris and pityriasis 
rosea, and in some cases of ringworm, psoriasis, syphilis, and 
seborrhoea corporis. 

The patches of grouped vesicles upon reddened bases located 
over the course of a cutaneous nerve in zoster. 



The Differential Diagnosis of Ringed Eruptions. 1 

The eruptions that appear, either habitually or occasion- 
ally, in ring-shape are trichophytosis corporis, syphilis, 
psoriasis, erythema multiforme, seborrhoea sicca, pityriasis 
maculata et circinata, and, rarely, favus of the body in its 
so-called herpetic stage. These eruptions often bear so 
strong a resemblance to one another that it is hard for even 
experts to make a positive diagnosis. It is, therefore, small 
wonder that the physician who has not had much experience 
in skin diseases should sometimes make an error in diagnosis. 
Happily, each one of them does have certain so well-defined 
features that a sure diagnosis can be made in the great ma- 
jority of cases. It is my desire to indicate the points in 
differential diagnosis between them. 

Trichophytosis, or ringworm, may be taken as the type of 
ringed eruptions. It must be clearly understood at the outset 
what we mean by an annular or ringed eruption. It is one 
that has a well-defined raised border surrounding a patch of 
skin that is normal or nearly so, or in which active disease 
has ceased. A circular patch, such as is seen in alopecia 
areata, is not a ringed eruption, as it does not present a 
w T ell- defined raised border, and the whole patch is equally 
affected. In ringworm we have a well-defined, slightly 
raised border composed either of vesicles, rarely seen, or 
pustules, or papules that are slightly scaly, or of small 
crusts, the remnants of the vesicles or pustules. Inside of 
this ring the skin may show no change, or be slightly scaly, 
the scaliness diminishing toward the centre. The eruption 
usually itches slightly. There may be only one patch, or 

1 American Medico-Surgical Bulletin. 



32 GENERAL CONSIDERATIONS. 

several in different stages of development. If there is any 
doubt about the diagnosis, it will readily be cleared away by 
examining some of the scales under the microscope, when 
if it be trichophytosis the fungus will be found with ease. 

This form of ringed eruption differs from syphilis : in 
itching; in having a narrow border made up of scales, 
vesicles, pustules, or crusts ; in its scaly centre ; in being 
superficial ; and in its microscopical characters. It differs 
from psoriasis : in its superficial character ; in its border 
not being covered with silvery scales ; in not being a gen- 
eral eruption ; in its parasite, and in not being of a pinkish- 
red color. It differs from erythema : in not being a sym- 
metrical eruption ; in its narrow border ; in its color, that 
cannot be made to disappear under pressure, and in having 
a fungus- growth as its cause. It lacks the greasy character 
of seborrhoea sicca, and differs from the latter also in the 
presence of the trichophyton fungus. It differs from pity- 
riasis rosea : in not being a general eruption ; in its centre 
being slightly grayish, and not of the appearance of chamois 
leather ; and in being parasitic. 

Syphilis at times shows itself in rings. These have one 
striking negative character, and that is, that they do not itch 
or burn. All the other ringed eruptions either itch or burn 
to a greater or less degree. It has a well-marked, rather 
broad, slightly elevated border, which is infiltrated, raw-ham 
colored, and composed of either scaling papules or of nodules. 
The centre of the ring may be normal, scaly, crusted, super- 
ficially or deeply cicatrized, reddened, or pigmented. Some- 
times the nodules of the border may break down and ulcerate. 
Occurring on the palms or soles, the border may be hardly, 
if at all, elevated, but simply red and scaly. This is due to 
the thickness of the epidermis in these regions. It is quite 
characteristic of the annular syphilide that it is often an in- 
complete ring, the border being broken at some point. The 
diagnosis will be aided by finding other evidences of syphilis, 
which usually are to be found. This form of ringed erup- 
tion differs from ringworm in the way already indicated. 
As it is quite possible for a syphilitic subject to have any of 
the other ringed eruptions, a history of the case will some- 



DIAGNOSIS. 33 

times be unreliable, if depended on for diagnosis. It is, 
therefore, better to make the diagnosis solely on what we 
see. It is only in very doubtful cases that a history of the 
eruption is desirable to help us to decide aright, and then 
only after a careful weighing of the evidence. A ringed 
syphilide is most apt to be confounded with psoriasis, but it 
differs from it : in having a raw-ham and not a pinkish-red 
color ; in not itching ; in showing a red seam beyond the 
scales ; in the scales being less silvery, smaller, and more 
abundant ; in the makeup of the border of individual lesions ; 
in not being so generally distributed over the body ; and in 
not occurring in the characteristic sites of psoriasis — that is, 
on the elbows and knees. If the case were psoriasis, there 
would surely be some characteristic patches to guide us. 
Erythema multiforme is so unlike syphilis in every respect 
that it is hardly possible they could be confounded. Seb- 
orrhoea corporis is located on the chest and between the 
shoulder-blades, and there will be found at the same time 
seborrhoea on the scalp. These are not characteristic of 
syphilis. Moreover, syphilis lacks the greasy feel of sebor- 
rhoea. The raw-ham color of the syphilide is never seen in 
seborrhoea. Pityriasis rosea is readily distinguished from 
syphilis by the occurrence at the same time of both macules 
and rings, by its lighter color, and by the chamois-leather 
look of the contents of the rings. The infiltrated border of 
the syphilide distinguishes it from all the other ringed erup- 
tions. 

When psoriasis forms rings it does so by the clearing up 
of the centres of old patches, and there will be character- 
istic patches of psoriasis to guide us in diagnosis. The 
border of the ring is usually quite broad and slightly, if at 
all, thickened ; its color is the pinkish-red of psoriasis, and 
the scales that cover it are large and silvery. The centre 
of the ring is composed of normal skin, which may be a 
little red. The scaling will be seen to be commensurate 
with the redness. It is commonly itchy. 

The differential diagnosis from syphilis and ringworm has 
been given above. Like the syphilide, it bears no resem- 
blance to erythema, except in its ring-shape. From sebor- 



34 GENERAL CONSIDERATIONS. 

rhcea it differs in not being greasy and in its silvery scales. 
At times the two diseases do bear a close resemblance to 
each other, but even then it will usually be easy to find 
some typical lesions of one or the other disease to decide 
the matter. There is little likelihood of confounding psori- 
asis with pityriasis rosea, as the former is much less super- 
ficial than the latter, and its scales are large and silvery, 
and not small and adherent ; besides, it lacks the chamois- 
leather color, which is a marked feature of pityriasis rosea. 

Erythema multiforme or erythema exudativum not infre- 
quently forms rings by the absorption of the centres of large 
tubercular lesions or patches. It is easy to recognize the 
lesion, as there will be other and characteristic erythematous 
lesions to guide us. The border of the ring is raised and 
its color is red, the redness, as in all erythematous lesions, 
being readily made to disappear on pressure, to return 
promptly when the pressure is removed. When the lesion 
has lasted for some time the color becomes darker and can- 
not so readily be made to disappear, because now the color- 
ing-matter of the blood remains behind in the tissues. The 
centre of the ring is red or discolored on account of the par- 
tially absorbed exudate. Another form of ringed erythema 
is what is known as erythema or herpes iris, in which we 
have either a purplish spot surrounded by a raised whitish 
ring containing fluid, and outside of this a red areola ; or a 
vesicle in the centre with a purplish zone about it, a raised 
whitish ring containing fluid, and a red areola outside of all; 
or a central bulla with one or two rings of vesicles about it. 
This form of erythema is usually symmetrical, and occurs 
upon the extensor surfaces of the arms and legs and upon 
the backs of the hands and feet. It may occur as part of a 
general erythema multiforme or by itself. The ringed 
erythema is so peculiar in its features as to offer little diffi- 
culty in differential diagnosis, and need not detain us further. 

Seborrhoea sicca, or seborrheal eczema, as it is now 
called, is the lichen annulatus of Wilson and the sebor- 
rhoea corporis of Duhring. It forms ring-shaped lesions 
on both the scalp and trunk. These are best and most 
often seen on the trunk, but may also be found on the 



DIAGNOSIS. 35 

limbs. Their favorite sites are the chest and the back be- 
tween the shoulder-blades. The rings are of large and 
small size, and at the same time there will be found fatty 
plates with more or less redness, the usual lesions of sebor- 
rhoea sicca. The border of the ring may be broad or narrow. 
If the former, then it will be formed of greasy crusts upon 
a reddened base ; if the latter, the border will be seen to be 
made up of a number of red points, the open mouths of the 
follicles of the skin ; or the border may be narrow and yet 
made up of fatty crusts. The skin in the neighborhood is 
commonly greasy, and the enclosed area of skin will look as 
if varnished, being glazed and yellow. 

The differential diagnosis from ringworm, syphilis, and 
psoriasis has been given already. The greatest difficulty is 
often found in the diagnosis from pityriasis rosea, especially 
when the ringed lesions are on the legs. The resemblance 
is then so great that it has led some to question if both 
the seborrhoea and the pityriasis are not forms of eczema. 
As a rule, the seborrhoeal lesion is more fatty and yellow, 
while that of pityriasis is more scaly, and the contained 
skin is more wrinkled and chamois-leather-looking. In 
typical cases there will be no difficulty in the diagnosis if 
the characteristics of both diseases are borne in mind. The 
presence of a seborrhoea on the scalp is corroborative evi- 
dence of the seborrhoeal nature of a doubtful eruption. 

Pityriasis rosea, or pityriasis maculata et circinata, not 
only shows rings, but also, as its name indicates, macules, 
and both forms of lesions are always present at the same 
time. It can be easily seen that the primary lesion is a 
pale- red papule, increasing in size, to become later a rosy- 
red lesion, which, after attaining a certain size, clears up in 
the centre, so as to form a ring with a pale-red border and 
a yellow, old-parchment, or chamois-leather-like centre. 
Both the borders and inclosed areas are slightly scaly. It 
is usually most pronounced on the chest and shoulders, but 
it may be a general eruption, though the hands, feet, and 
face are rarely affected. Its differential diagnosis has been 
given under the previously described diseases. 

It is a property of all these eruptions that, if two or more 



36 GENERAL CONSIDERATIONS. 

of their rings appear near each other, they are very apt to 
run together and form figure-of-eight or gyrate lesions from 
the disappearance of the borders at the part where contact 
has taken place. 

The ring-shaped or herpetic form of favus is not com- 
monly seen. It occurs in favus of the body. It will then 
bear so strong a resemblance to ringworm that at first it is 
impossible to distinguish which it is ; but it is only neces- 
sary to wait a short time, when a well-marked favic cup will 
develop. 

Lichen planus papules, when they have crowded together 
into a patch, will form into rings at times by the absorption 
of the central papules. The ring is never of large size ; its 
color is the peculiar violaceous color of lichen planus ; the 
centre is depressed, and the whole is scaly. As these rings 
are never seen apart from the simultaneous occurrence of 
characteristic flat, angular, smooth papules, with central 
umbilication, there is no possibility of confusing them with 
those of the other ringed eruptions. 

We occasionally see rings in lupus erythematosus and in 
epithelioma, but such occurrences are exceptional. When 
they do occur, the other signs of the one or the other dis- 
ease will be so much in evidence that there will be little 
danger of mistake in diagnosis. 

Lupus erythematosus has a peculiar red color ; its border 
is usually covered with closely adherent scales, and the ring 
will have a cicatricial centre. At the same time there will 
be other patches present of typical lupus erythematosus. 

Epithelioma, even when it does form a ring, has that char- 
acteristic hard, raised, waxy border, which we see in all epi- 
theliomas of the skin, and that will be enough for diagnosis. 

Color. An eye for color is of some value in diagnosis. 
It is very difficult to convey by words a correct idea of the 
color of an eruption, but perhaps this list may prove helpful : 

Raw ham of syphilis. 

Brilliant red of erysipelas. 

Inflammatory red of eczema. 

Dark red of purpura. 



DIAGNOSIS. 37 

Bright red of psoriasis. 

Brown of pigmentary diseases. 

Sulphur-yellow of favus. 

Buff of xanthoma. 

Violaceous or dull red of lichen planus and lupus ery- 
thematosus. 

White of leucoderma. 
History. Having carefully noted all these objective 
symptoms, we have by this time pretty well made up our 
minds as to the diagnosis of the case. Now is the time to 
obtain the history of the case, either for the purpose of 
scientific study of its etiology and natural course, or for the 
purpose of clearing up some doubt as to our diagnosis. It 
is so easy to obtain a history of syphilis that, were we influ- 
enced by the history, we would be often misled. There is 
no reason why a patient with syphilis should not have any 
other skin disease. Moreover, most people do not pay 
much attention to the history of their diseases, and it would 
be difficult for them to give a correct account of themselves, 
if they would. Of course, a clear history of the initial 
lesion of syphilis, or its presence, would clear up any doubt 
as to an erythematous rash. The history of a scaly disease 
recurring at frequent intervals upon the elbows and knees 
would go far to determine the existence of psoriasis. In 
urticaria we have to rely upon the statement of the patient 
or attendant as to the appearance of the wheals, as their 
presence at some time is pathognomonic, and they are usually 
absent when we see the patient. In these and similar ways 
the history is useful, but it should be entirely subordinated 
to the study of the objective symptoms. 

Pruritus. It is important to know whether a disease 
itches or not. This we can discover by the presence or 
absence of scratched papules or scratch-marks. The itching 
eruptions are eczema, pruritus cutaneous, prurigo, urticaria, 
dermatitis herpetiformis, pediculosis, and scabies. The symp- 
tom is also present in the lichens, trichophytosis, seborrhoea, 
and psoriasis. It is markedly absent in syphilis, though an 
occasional case of syphilis will be encountered in which there 
is itching. 



38 GENERAL CONSIDERATIONS. 

Burning. The sensation of burning is one the exist- 
ence of which we must take upon the patient's statement. 
It is a prominent symptom in erythema. Very often a 
patient will say that his eruption itches ; but if you watch 
him, he will soon begin to rub his skin gently with the heel 
of his hand. This indicates that the sensation is one of 
burning and not of itching. In itching, the nails are used, 
or else the rubbing is vigorous. 

Pain. Another symptom for the establishment of which 
we have to rely upon the patient is that of pain. The vast 
majority of skin diseases, while they may cause more or less 
discomfort, are not painful ; but sharp neuralgic pain is a 
prominent symptom in epithelioma and zoster. The pres- 
ence of pain of a shooting character will be one point in the 
differential diagnosis between lupus and epithelioma, and 
in favor of the latter. 

Microscope. The principal use of the microscope in the 
hands of the general practitioner is, as far as dermatological 
diagnosis is concerned, the determination of the presence or 
absence of fungi in hair and scales in a doubtful case of 
ringworm, favus, chromophytosis, or other parasitic disease. 
As a matter of fact, it is very difficult to determine whether 
the mycelia and spores found in a hair are those of favus or 
of ringworm, unless the manifestations of the disease on the 
scalp are known and seen. Happily as between favus and 
ringworm we seldom have need of the microscope for diag- 
nosis, their symptoms being so pronouncedly different. 

A few words must be said about the methods of examina- 
tion of patients. They should be always examined by day- 
light or by electric light. It is prudent to refuse to give an 
opinion of a case when seen in a poor light, or by artificial 
light. If the patient is a man, it is but just to yourself to 
request him to strip from top to toe, if there is the slightest 
need of seeing more than the ordinarily exposed parts. In 
the case of a woman such an inspection can seldom be made. 
The same end can be attained by exposing one part after 
the other. In all cases you are justified in refusing to treat 
a case that you have not been given ample opportunity to 
examine. 



THERAPEUTIC NOTES. 39 

All examinations of patients should be made in a warm 
room. The contact of cold with the usually covered skin is 
apt to give it a mottled look that obscures the diagnosis. It 
is well never to give a diagnosis of an obscure case that is 
under local or constitutional treatment, until all treatment 
has been suspended for a few days and the disease allowed 
to assume its natural appearance. 

Under the name of diaskop Unna has recommended the 
use of a small piece of thick, clear glass, marked with a meas- 
uring-scale, for the purpose of exercising pressure upon the 
skin under examination. This does away with the confus- 
ing redness and brings into greater prominence anatomical 
lesions. 

Every patient should be regarded as possibly out of health 
in some way quite apart from his skin trouble, and exam- 
ined as to the performance of all his functions quite as care- 
fully as if he had come to you for the treatment of some 
internal disorder. 



Therapeutic Notes. 

In the second part of this book there will be found the 
treatment suitable to the various diseases. In this place my 
object is to give the reader a few notes upon some of the 
newer remedies for skin diseases. At present a new remedy 
is brought out nearly every month that promises to do better 
than any of its predecessors; but careful comparative tests 
demonstrate that many of them are no better than the old 
and tried ones. It is better for the general practitioner to 
learn how to use a few drugs than to try every new thing. 
By practical experience he will be surprised to see how much 
he can accomplish with a very small assortment of drugs. 

The old-fashioned excipients for drugs for application to 
the skin were water, lard, and oils. Then vaseline and cos- 
moline and other petroleum-derivatives were taken up. 
These were all disagreeable to use because they were 
greasy. Then liquor gutta-perchce (traumaticin) and flex- 
ible collodion were introduced, and are still used. They are 



40 GENERAL CONSIDERATIONS. 

not greasy ; they prevent the clothing from being soiled ; 
give us a fixed dressing, and exert a certain amount of pres- 
sure upon the skin that is useful in some cases. They are 
most used in the treatment of psoriasis, ringworm, and in 
circumscribed chronic diseases. In acute diseases, and spe- 
cially where there is more or less exudation, they cannot be 
used. 

Plaster-muslins were devised by Unna. They are made 
by spreading upon muslin a mixture of gutta-percha and 
oleate of alum. With the plaster-mass many drugs can be 
combined. 

Salve-muslins we also owe to Unna. They consist of a 
salve-mass composed of benzoated mutton tallow and wax, 
with which various drugs are combined. The muslin is 
dipped into the melted mass, then dried, and rolled flat and 
smooth, either on both sides or on one side. Machinery is 
used for the purpose. 

Pastes answer admirably for the acute and exudative con- 
ditions, as they protect the part and at the same time allow 
the exudate to work up through them, and thus escape. 
Lassar's paste, composed of zinc oxide, starch, and vaseline, 
as set forth in the formulary at the end of this book, was 
one of the first of these, and is still probably more used than 
any of them. Various other pastes have been proposed. 
It is found that infusorial earth (Kieselguhr) added to any 
ointment in the proportion of 10 per cent, will form a good 
paste. 

Gelatin preparations, one of which is given in the for- 
mulary, were introduced as preferable to ointments, and many 
German and English authorities speak well of them. They 
are troublesome to apply because they have to be heated be- 
fore being used, and take a good deal of time to set. They 
have not become popular in this country. 

Under the name of skin splints Unna 1 has introduced a 
method of applying dressings in skin diseases that is cer- 
tainly ingenious. Pressure is often wanted. It should be 
even. It is also desirable that such dressings should be 

1 Monatshefte f. prakt. Dermat,, 1893, xvii. p. 481. 



THERAPEUTIC NOTES. 41 

durable, not readily dislodged, and easily removed and re- 
placed. For this purpose the part to be dressed is first 
covered with a layer of plaster- or salve-muslin, or simple 
bandage-muslin. This is painted over with a preparation 
composed of gelatin and glycerin, of each 15 parts ; water 
40 parts, and oxide of zinc 30 parts. When this is set it is 
painted over with a 1 per cent, solution of chromic acid, 
the green color of which may be covered by applying a var- 
nish of zinc oxide and shellac. If a hairy part is to be 
dressed, and it cannot be shaved, the hairs should be greased. 
To remove the dressings it is only necessary to raise the edge 
and to touch the under side of the plaster with absorbent 
cotton wet with benzine. Variously medicated salve- or 
plaster-muslins are to be used according to the nature of 
the case. 

George H. Fox 1 has brought out a series of elastic web- 
king, broad rings of various sizes, that are admirable for re- 
taining dressings in place. They serve the purpose of 
Unna's skin splints without any trouble either to the patient 
or physician. 

In 1891 two excellent excipients were brought to our 
notice : one that is made from gum tragacanth, and called 
Bassorin ; and one that is made from Irish moss, and 
called Plasment. They both sink well into the skin, leav- 
ing a protective film on it that can be readily removed with 
water. Salve-pencils and paste-pencils were both invented 
by Unna. As the name indicates, they are prepared of 
salves or pastes, cast or moulded into the form of sticks 
about as thick as the little finger. The former contains oil 
and the latter does not. 

Medicated soaps, specially those containing an excess of 
fat, have been brought out in great variety during the past 
years, and possess certain virtues, though as a rule a soap is 
not the best vehicle for medication. They are cleanly, can 
be readily removed from the skin with water, and can be 
made to produce a greater or less effect according to 
whether the lather is allowed to remain or not. 

1 New York Med. Journ., 1895, lxii. p. 594. 



42 GENERAL CONSIDERATIONS. 

Under the name of oleum physeteris or chamoceti, a spe- 
cies of whale-oil was recommended by Guldberg 1 as an ex- 
cellent excipient. Oleic acid is another vehicle that pos- 
sesses the virtue of penetrating the skin. Lanolin and 
agnine, derived from the wool fat, are among the newer 
greasy applications that are supposed to penetrate the skin. 
Both possess a peculiar odor, unpleasant to many. This is 
most marked in lanolin. It can be masked by combining 
with other ointments and by perfumes such as rose water. 
Adeps lanm is another of the newer bases for ointments. It 
is said to be unirritating, and to be capable of taking up 300 
per cent, of water without losing its salve-like consistence. 
(Esypus, a refuse-product obtained in cleansing sheep wool, 
belongs to the same class of remedies. It is a disagreeable- 
looking stuff with a bad odor, and will not come into favor 
in this country. The property of penetration is not a virtue 
in all cases by any means, as in very many of our cases we 
wish to provide merely protection. 

Resorbin is a mixture of almond oil, wax, water, and a 
small amount of a solution of gelatin. It combines readily 
with fats. It is commended for its penetrating powers, and 
is said to cool the skin, and allay itching and inflammation. 
It is used alone and as an excipient in many diseases of the 
skin. 

Myronin is a yellow, slightly aromatic, butter-like sub- 
stance, for which penetrating powers are claimed. It is said 
to be a good excipient for mercury when used for inunctions, 
and for zinc oxide in intertrigo and dry eczemas. 

In the way of drugs of comparatively recent date we 
have : 

Airol, a combination of bismuth, iodine, and gallic acid, 
of gray-green color, odorless and tasteless, which is sup- 
posed to have the virtues of iodoform and to be more active ; 
can be used as a dusting-powder or as an ointment with 
vaseline. 

Alumnol is a fine, white powder, non-hygroscopic and 
stable. It is soluble in water to the extent of 45 per cent., 

1 Monatshefte f. prakt. Dermat., 1890, x. No. 10. 



THERAPEUTIC NOTES. 43 

forming a permanent solution. Used as a powder (12 to 25 
per cent.), ointment (1 to 12 per cent.), or in collodion (5 
to 10 per cent.), it is recommended in acute and chronic 
eczema, various dermatitides, trichophytosis, chromophyto- 
sis, and contagious impetigo. 

AntJirarobin was proposed as a substitute for chrysa- 
robin, but it is a weak preparation, and has not proved of 
special use. 

Aristol is a good dressing for ulcers used in the form of 
a powder. It is expensive, but a good substitute for iodo- 
form in some cases, as it is devoid of odor. I have made 
many comparative tests with it and older remedies in treat- 
ing ulcers, and have found in the great majority of cases 
that the old friends were the best. In 10 per cent, strength 
it has been commended in the treatment of psoriasis, ery- 
sipelas, hyperidrosis, eczema, acne, rosacea, and all sorts of 
ulcers. 

Creolin, in 1 to 5 per cent, solutions in water, is often 
useful in erysipelas, dermatitis, and as an antiseptic. It is 
very irritating to some skins. 

Dermatol, a subgallate of bismuth, is said not to cake, and 
not to be poisonous. It is used as a powder for fresh wounds, 
forming a crust under which healing takes place. For ex- 
coriations, intertrigo, and slightly moist eczema it is to be 
mixed with equal parts of starch. For large, irritable ulcers 
it may be used as an ointment of 10 per cent, strength or as 
a powder. 

Emol is a soft, impalpable powder of delicate pink hue. 
It is analogous to fuller's earth. It softens hard water 
when added to it, and with warm water forms a natural soap, 
leaving the skin feeling pliable and soft. It is said to be a 
good dusting-powder, and to possess remarkable power in 
separating and causing to fall horny patches of eczema and 
keratosis. For this purpose it is made into a paste with 
water, and, when applied, it is covered with oiled silk or 
rubber tissue. 

Europhene. An amorphous powder of yellow color and 
aromatic odor, containing 28 parts of iodine in 100. Insol- 
uble in water and glycerin ; readily soluble in ether, chloro- 



44 GENERAL CONSIDERATIONS. 

form, collodion, and traumaticin. Useful in venereal ul- 
cers and mucous patches in pure powder or 2 to 5 per cent, 
ointment. Also in tertiary syphilis as hypodermic injec- 
tions in the vicinity of the lesion, and in solution in oil. 

JFuchsine, and other aniline dyes, in 1 per cent, solution 
in water, are recommended as useful in ringworm, inopera- 
tive cancerous ulcers, erysipelas, and other local infectious 
diseases. 

Gallacetophenone, made by the action of acetic acid upon 
pyrogallol, was brought out in 1891 as remarkably efficient 
in the treatment of psoriasis. It may be used in 5 to 10 
per cent, strength in ointment or collodion, does not stain 
the clothing, and thus far has proved neither poisonous nor 
very efficacious. 

Hydroxylamine is poisonous when absorbed. It was 
commended for psoriasis, but cannot be used over large 
surfaces. It has been commended in lupus vulgaris and 
ringworm of the scalp and beard — a grain and a half of the 
hydrochloride being dissolved in an ounce and a half each 
of alcohol and glycerin. It has not gained popular favor. 

Ichthyol, especially the ammonio-sulphate, is useful, ac- 
cording to its introducer, Unna, and many others, both for 
external and internal use in rosacea, acne, eczema, urti- 
caria, erythema, herpes, dermatitis herpetiformis, seborrhcea, 
furunculosis, erysipelas, psoriasis, sycosis, lupus, and some 
other dermatoses. By the mouth it is best exhibited in 
capsules, from three to fifteen drops being given during 
the day. Externally it is exhibited in solution in water, or 
in paste-form, and in the strength of 2J to 10, 20, or 50 
per cent. 

Liquor anthracis simplex and compositus are thin fluids 
prepared from coal tar, which are said to be non-poisonous 
and to be useful in chromophytosis, trichophytosis, and 
chronic eczema. The compound fluid contains sulphur, 
resorcin, and salicylic acid. 

Myronin is a yellow, slightly aromatic substance, of 
butter-like consistence, that is said to be a good excipient 
for ointments. 

Oxynaphthoic acid is recommended by Schwimmer for 



THERAPEUTIC NOTES. 45 

scabies and prurigo in 10 per cent, strength in ointment. 
His ointment for scabies is composed of ten parts each of 
the acid, chalk, and green soap, to eighty or one hundred 
parts of lard. 

Hesorcin is recommended for seborrhcea capitis, beginning 
in 2 per cent, strength, and increasing up to 5 or 10 per 
cent., as the acute stage lessens; for psoriasis, 10 to 20 per 
cent. ; eczema about the mouth, 2 per cent. ; erysipelas ; and 
as a plaster for keloid and malignant growths. Strong 
preparations, say 20 to 30 per cent., can be used in acne 
and rosacea for the purpose of producing a dermatitis, to be 
followed by peeling off of the old skin. It must be remem- 
bered that this drug in weak strength promotes cornification, 
while in strong solution it macerates the skin. This class 
of remedies is called "reducing" agents and to it belongs 
sulphur. 

Salol y two parts to one of starch, is commended for use in 
ulcers. 

Stgresol is an antiseptic varnish composed of gum lac, 
benzoin, balsam of tolu dissolved in alcohol, and a small 
amount of carbolic acid or phenol. It is recommended 
especially because it adheres to the mucous membrane as 
well as the skin, and has been found useful in various ulcers 
and in chronic eczema. 

Tar. Compound tincture of coal tar is commended by 
Duhring as a substitute for liquor carbonis detergens. It 
is made by digesting one part of coal tar with six parts of a 
tincture of quillaja (1 to 4 in 95 per cent, alcohol). It is 
used diluted, 15 minims to the ounce of water. 

Thilanin is lanolin acted on by sulphur, and containing 3 
per cent, of the latter. Recommended for acute and chronic 
eczema, and in lupus erythematosus. 

Thiol, which is miscible with water, and is used in the 
strength of 20 per cent, in liquid or powder form, is said to 
be useful in seborrhcea, rosacea, acne, eczema, burns, pem- 
phigus, dermatitis herpetiformis, impetigo, and zoster. It 
is a chemically prepared imitation of ichthyol. As it is 
free from the disagreeable odor of the latter drug, it is prefer- 
able to it in some cases. 

3* 



46 GENERAL CONSIDERATIONS. 

Tumenol. Used in solution with equal parts of ether, 
alcohol, and water, or glycerin, or in form of paste or oint- 
ment. Useful in moist eczema, burns, ulcers, and rhagades. 



Classification. 

In the present state of our knowledge it is impossible to 
make a satisfactory classification of skin diseases. Many 
attempts have been made to do this, and are still being 
made. Nearly every systematic writer tries his hand at it 
with more or less indifferent success. The most scholarly 
classification is that by Prof. E. B. Bronson (Journ. Cutan. 
and Gen.- Urin. Dis., 1887, v. 369), which is founded on 
that of Auspitz. Hebra's classification modified is found in 
a great many text-books. The arrangement of this book 
does away with classification, with which the student need 
not burden his mind. 



Some Dermatological Dont's. 

Don't make your diagnosis from the history of a case, 
because if you do you will often be led astray. Make it 
from the eruption that you see, and then substantiate or 
destroy this by the history of the case, if you will. 

Don't fail to think of the possibility of every case being 
either syphilis or eczema; and 

Don't fail to master these two diseases as thoroughly as 
possible, because if you learn to recognize these two you 
will have gone a long way in diagnosis. If they can be 
excluded, then the field of possible " might be's " is con- 
siderably narrowed. 

Don't make the diagnosis of syphilis on account of a 
syphilitic history, because you can often get a history of 
syphilis in a non-syphilitic case. 

Don't expect much, if any, history of syphilis in a 
woman, because you very frequently will not get it. In 



SOME DERMATOLOGICAL DONT'S. 47 

them the early symptoms of the disease are often so slight 
that they are not observed by them. 

Don't throw out the diagnosis of syphilis on account of 
an eruption itching, because some syphilides, especially the 
papular variety, do itch at times. The not itching of an 
eruption is better presumptive evidence of syphilis than is 
itching positive evidence against it. 

Don't make the diagnosis of lichen planus from the pres- 
ence of flat angular papules with depressed centres alone, 
because identical lesions will at times be met with in eczema, 
syphilis, and psoriasis. 

Don't depend upon getting the bleeding-points springing 
out of the delicate pellicle after carefully scraping off the 
scales, for your diagnosis of psoriasis, because you can pro- 
duce the same thing in other diseases. In fact, 

Don't depend upon any one symptom, but make your 
diagnosis from the general make-up of the disease as a 
whole. 

Don't forget that many diseases of the skin are depen- 
dent upon disturbances in the general health of the patient. 
Therefore, 

Don't fail to inquire into the performance of the functions 
of the various organs of the patient, and to put him into as 
good a physical condition as possible. 

Don't tell your patient that it is dangerous to cure his 
skin disease rapidly, because it is not. If you 

Don't know how to treat the case, ask advice of someone 
who does. 

Don't encourage the popular notion that there is danger 
of an eruption striking in, because it never does. 

Don't give arsenic for every skin disease, and, especially, 

Don't give it in acute eruptions. Its sphere is in the 
chronic scaly eruptions, such as chronic psoriasis. 

Don't forget that most cases of pruritus are due to in- 
ternal causes, and that in them external treatment is wasted ; 
and 

Don't forget the bed-bug and the pediculus as possible 
causes of the trouble. 

Don't forget that the greatest secret in the treatment of 



48 GENERAL CONSIDERATIONS. 

eczema, and many other skin diseases, is not what particu- 
lar drug or formula is "good for" the disease, but a knowl- 
edge of the great principle that acute diseases need soothing 
remedies, and subacute and chronic diseases need stimula- 
tion. 

Don't expect to cure an inveterate eczema with thickened 
skin by means of a soothing ointment, such as that of the 
oxide of zinc, because you will only waste your time and the 
patient's money. 

Don't use tar in an acute eczema, because it is a stimu- 
lant, and what we want at this time is to soothe the in- 
flamed skin. It is appropriate to a subacute or chronic 
case. 

Don't allow water to touch the skin in acute eczema, 
because it always irritates in such a case. 

Don't use a thick ointment on the hairy scalp, because 
it makes a disagreeable mess of the hair, and will not be 
" popular" with your patient. Even lard is not a pleasant 
vehicle for such applications. Vaseline and the oils are 
more elegant excipients. 

Don't order the hair to be cut from the head of a young 
or old woman in any disease of the scalp, because, except in 
the case of a peculiarly stupid or careless patient, it is never 
necessary, and always disagreeable to the woman. 

Don't allow a patient with ringworm to go to school, be- 
cause if you do you will be responsible for the spread of the 
disease. 

Don't pronounce a ringworm case well and incapable of 
spreading the contagion until you are sure that it is well ; 
and 

Don't be sure about it until there are no more " stumps " 
on the scalp, and you can find no more of the fungus in the 
hair. 

Don't use the name "barber's itch" for anything but 
trichophytosis barbae, because it is well not to use terms 
loosely to cover several different diseases. 

Don't use chrysarobin on the face or scalp, because it is 
very apt to cause a good deal of dermatitis with oedema, and 
to stain the skin a deep mahogany-red. 



SOME DERMATOLOGICAL DONTS. 49 

Don't forget to caution a patient to whom you have given 
chrysarobin not to touch his face with his hands after 
applying the drug, because if you do you will have either a 
mad or a frightened patient in your office. 

Don't pronounce a patient addicted to the excessive use 
of alcoholic beverages on account of his having rosacea, be- 
cause there are lots of other things besides alcohol that will 
cause it. 

Don't use the positive pole of the battery for the needle 
in destroying hair by electrolysis, because if you do you will 
leave more or less permanent marks in the skin. 

Don't apply a sulphur preparation after using a mercurial 
upon the face, or vice versa, because if you do you will raise 
a fine crop of comedones. 

Don't use a camel's-hair brush for making applications 
of corrosive sublimate, because if you do some of the salt 
will be left on the brush each time it is used, and you will 
soon have a stronger solution than you bargained for. Al- 
ways use a little cotton on a wooden toothpick, or a splinter 
of wood. 

Don't allow a fine-toothed comb to be used on the scalp, 
because it scratches and irritates the scalp. 

Don't encourage or advise the use of pomades on the 
healthy scalp, because they are prone to become rancid and 
inflame the scalp. They are also unnecessary if the hygiene 
of the scalp is properly looked after. 

Don't forget that dandruff is the most frequent cause of 
premature baldness, because if you remember this you may 
be able to prevent the fall of someone's hair for some time. 
Therefore, 

Don't fail to treat every case of dandruff. — The Medical 
Record, December 29, 1888. 



PAET II. 

THE DISEASES OF THE SKIN AND THEIR 
TREATMENT. 



Scheme of Pronunciation". 

ape ; A 2 , at ; A 3 , ah ; A 4 , all ; Ch, chin ; Ch 2 , loch (Scottish) ; E, he ; 
E ? , ell ;'■ G, go; I, die ; I 2 , in ; N, in ; N 2 , tank ; O, no ; O 2 , not ; 
O 3 , whole; Th, thin; Th 2 , the; U, like oo in too; U 2 , blue; U 3 , 
lull ; U 4 , full; U 5 , urn; U 6 , like u (German). 1 



Abscess (A 2 b , -se 2 s). 

Symptoms. Abscesses are very frequently met with as 
complications of diseases of the skin, such as acne, eczema, 
scabies, pediculosis, and other acute dermatitides. As thus 
met with, they are usually of small size, though at times, as 
upon the scalp of a strumous child, they may attain con- 
siderable dimensions. Their most frequent locations are : 
upon the scalp with eczema ; upon the face and back with 
acne ; and upon the extremities with scabies and pediculosis. 
Apart from a slight amount of discomfort, they do not give 
rise to subjective symptoms as a rule, and are indeed trivial 
affections. Of course, this does not apply to abscesses as 
seen by the surgeon. They may open of themselves and dis- 
charge their contents upon the skin. More commonly they 
are very sluggish in their course, and must be evacuated by 
some surgical procedure. 

Diagnosis. An abscess differs from a furuncle by not 
being raised ; not having a central core ; and by being less 

1 From Foster's Illustrated Encyclopaedic Medical Dictionary. New 
York, 1890. By permission. 



ACANTHOSIS NIGRICANS. 51 

firm to the touch. It differs from a carbuncle by an entire 
absence of marked constitutional disturbance, brawny infil- 
tration, intense inflammation, and cribriform mode of open- 
ing. Kerion often resembles an abscess, but differs from it 
in its uneven surface and the welling up of a mucoid fluid 
alongside of the hairs. Syphilitic gummata are sometimes 
mistaken for abscesses and opened. They may be recognized 
by their dark-red color, their absence of pain and discom- 
fort, and the history of their growth. They grow slowly, 
beginning below the skin. There are generally more than 
one present, and then they are grouped. The aspiration of 
the tumor will decide the question. From an abscess we 
obtain pus ; from a gumma a little bloody fluid. 

Treatment. The management of the small cutaneous 
abscesses that we meet with as dermatologists is simple. 
The cavity is to be opened, the pus allowed to escape, and 
the part dressed with carbolized vaseline if small, or anti- 
septically if larger. It is sometimes necessary to swab out 
the cavity with a strong carbolic acid solution to destroy the 
abscess wall and prevent the re-formation of the abscess. 

Absces Sudoripares. See Hidrosadenitis suppurativa. 

Abschilferung (A 3 b r -shi 2 l-fe 2 r-ung). Branny scaling of 
skin. 

Abschuppung (A 3 b / -shup-pung). Scaling or chapping. 

Acantholysis (A 2 k-a 2 n-tho 2 l'-i 2 -si 2 s). A disease character- 
ized by loosening or separation of the mucous layer of the 
epidermis. See Epidermolysis. 

Acanthosis Nigricans (A 2 k-a 2 n-tho'-si 2 s Ni 2 g-ri 2 k-a 2 ns). 
Under this name three cases have been reported — by Pol- 
litzer, Janovsky, and Crocker — one each. It consists in a 
dirty-brown to bluish-gray discoloration of the skin and 
mucous membranes, with more or less papillary outgrowths. 
On the places that are most discolored the papillary out- 
growths are most marked. The skin is thickened to a 
greater or less degree. The regions affected are the face, 
neck, mucous membranes of the mouth, the backs of the 
hands, especially the fingers, the axillae, groins, genito-anal 



52 DISEASES OF THE SKIN. 

regions, and abdomen. Treatment does not seem to be of 
any use. The cause of the disease is unknown. 

Acne (A 2 k'-ne). Synonyms: Varus, Ionthus; (Ger.) 
Finnen; (Fr.) Acn6, Bouton ; Stone-pock, Whelk, Pimple. 

Acne is an inflammatory disease of the sebaceous glands 
and the hair follicles, due to the retention of sebum ; char- 
acterized by an eruption of papules, pustules, or tubercles 
upon the face, neck, shoulders, or chest ; which usually begins 
at puberty, and tends to run a chronic course. 

Different writers and teachers have applied different 
names to the different phases of acne. These had best be 
forgotten, except in so far as they are of historical value. 
The term acne is applied by the French school to all dis- 
eases of the sebaceous glands. It would seem to be the 
wiser plan to reserve the name for the disease just defined. 
Regarded thus, we have but two varieties of true acne, and 
those are acne vulgaris and acne indurata. 

Acne Vulgaris or Simplex is either papular or pustular 
in character, though usually it is a combination of the two, 
together with more or less comedones scattered about. 

Symptoms. If only papules exist (A. papulosa), the 
face, shoulders, or chest will be found to be dotted more or 
less profusely with pinhead-sized, acuminated elevations of 
the skin, of a pinkish to red color, and with a central open- 
ing at the summit. Very often the central openings will be 
filled by blackish specks. The lesions are then spoken of 
as A. punctata. This term is used by some writers to des- 
ignate the comedo, but improperly, according to our defini- 
tion. It is rare that acne exists only in the papular form. 
More usually it will be found that here and there the pap- 
ules are surmounted by a pustule, or a pustule has taken 
the place of a papule. We now have A. pustulosa. In 
strumous subjects the pustular element preponderates over 
the papular, and the face may be greatly disfigured by the 
large number of the lesions present upon it. The pustules 
are from pinhead to small pea size, and have an inflamed 
base. (Fig. 5.) 

Together with the acne and the comedones, we meet with 



ACNE. 



53 



milia quite commonly, and the affected parts are usually 
greasy to the feel, showing that the sebaceous glands sym- 
pathize in the disease. We now have a fair picture of a 
typical case of acne vulgaris. The face, back, neck, or 
chest, or all four, are dotted over in an irregular manner 
with blackish points, papules, and small pustules ; the skin 
of the nose and forehead looks shiny and feels greasy, and 



Fig. 5. 




Acne vulgaris. 
(From Prof. George H. Fox's Service in the Vanderbilt Clinic.) 

perhaps there are some milia scattered about the region of 
the eyes. At times the face will look inflamed and hyper- 
semic, especially in young, otherwise robust, subjects. More 
commonly the complexion will have that pasty appearance 
indicative of what has from old times been called the 
strumous condition. If the inflammatory process has been 



54 DISEASES OF THE SKIN. 

unusually severe, we may find a considerable amount of 
scarring. Usually acne vulgaris does not leave permanent 
scars. The profuseness of the eruption varies greatly. In 
some cases there will be but a few lesions, while in other 
cases they will be present in vast amount. This form of 
acne generally occurs in young people. The duration of the 
individual lesion is short, as it soon either dries up or dis- 
charges its contents. If the papules are squeezed, little plugs 
of sebaceous matter will be expressed. If the papulo-pustules 
are treated in the same way, there will first be pressed out 
a small sebaceous plug, and then a drop or two of pus. 

Acne Indurata is a pustular acne, in which the pustules 
are of large size and seated upon deeply infiltrated bases. 

They are most commonly sparsely dispersed, and take 
the form of purplish "lumps" of pea to bean size, which 
are hard to the touch. Sometimes they are more readily 
appreciated by touch than by sight, being located deeply in 
the skin. Sometimes thev take the form of cutaneous ab- 
scesses, and if by chance several are located close to one 
another, they may run together and form a raised, dark- 
red, doughy mass. When incised, these lesions sometimes 
give exit to a large amount of thick pus. They usually 
leave scars, which sometimes are very disfiguring, unless 
they are opened very early in their course. They may be 
the only form of acne present, or they may be combined 
with acne vulgaris. This form of acne usually occurs at a 
more advanced age than does acne vulgaris, though it is not 
infrequently met with in early life. While occurring on 
the face, the neck and back are the regions in which it is 
prone to develop in the most marked manner. (Fig. 6.) 

Etiology. Acne is one of the most common of skin 
diseases, and its great predisposing cause is youth. The 
disease first shows itself about the time of puberty, and 
manifests a tendency to disappear when the body is fully 
developed — that is, from the twenty-third to thirtieth year. 
A few rare cases have been reported of acne at an early 
age. Thus, Chambard 1 has met with a case in a girl of six 

1 Annal. Derm, et Syph., 1878-79, x 259. 



ACNE. 55 

and a half years. The indurated form of acne appears later 
than the simple form, usually after the twenty-fifth year. 
Both sexes are aifected, but the disease is more frequent in 
females than in males, and in them begins at an earlier age. 
The period of youth is the time of great developmental 
activity in which the sebaceous glands take part, and it is 
probable that there is a too great activity of the glands, and 
an improperly formed sebum is the result. Normally, the 

Fig. 6. 




Acne indurata of the back. 

product of the fat-glands is an oily fat. In acne an inspis- 
sation of the fat takes place, forming a plug that acts as a 
foreign body and sets up an inflammation. 

Individuals with thick, pasty, pale skins, with patulous 
follicular mouths, are predisposed to acne. These peculiarities 
of skin are met with in scrofulous subjects. The patulous 
follicular mouths give ready lodgement to foreign matters, 



56 DISEASES OF THE SKIN. 

and comedones are thus formed. This prevents the escape 
of the follicular contents, a plug is formed, and we have an 
acne papule or pustule. Comedones are, therefore, an ex- 
citing cause of acne. 

Heredity has been asserted by some to be a predisposing 
cause of acne, but the disease is so common that there is no 
certainty about this factor. 

Of the exciting causes of acne, the most active one is 
some form of digestive disturbance. This may take the 
form of dyspepsia, stomachal or intestinal ; or it may be 
mal-assimilation ; or it may be failure on the part of the 
liver or pancreas to perform its physiological functions; or 
it may be sluggishness of the large intestine and consequent 
constipation. 

Next to disorders of the digestive organs, those of the 
sexual organs are supposed to have most influence in pro- 
ducing acne. But, inasmuch as most cases of acne are 
amenable to the influence of diet and regulation of diges- 
tive disorders without any attention being given to sexual 
disorders, it is probable that the latter are important etio- 
logical factors in comparatively few cases. Indeed, it is not 
improbable that the acne that appears on the faces of women 
at each menstrual period, and at that time alone, as well as 
the aggravation of an already existing acne, is due to the 
more or less pronounced disturbance of the digestive organs 
so frequently observed at the same time. In some cases 
acne does seem to be a reflex irritation from the uterus. 
Amenorrhoea is the uterine derangement most frequently 
encountered, but that condition is but one evidence of a 
general constitutional disorder, rather than a disease in itself. 

Masturbation and continence have each been blamed as 
excitants of acne. The former of these of itself does not 
cause acne, but its well-known effects on the nervous, moral, 
and physical condition of growing youths would sufficiently 
account for any part it may have in producing acne. There 
is absolutely no proof that continence causes acne. If a 
boy or young man keeps himself in a constant state of 
unrest by lascivious thoughts, that is not true continence, 
even though he does not masturbate or copulate. It is safer 



ACNE. 57 

for us to say that bad sexual hygiene may cause acne, 
rather than to ascribe it either to masturbation on the one 
hand, or continence on the other. 

It may be stated, as a broad general rule, that anything 
that lowers the general health of the patient contributes to 
the production of acne. We have space to enumerate only 
some of these exciting causes. Thus, we have the vague 
state "general debility," anaemia and chlorosis, oxaluria 
and uraemia, rheumatism and gout, poor circulation, mental 
and physical exhaustion, and chronic malaria. 

In 1881 Denslow 1 advanced the theory that a want of 
tone in the arrectores pilorum muscles, either alone or to- 
gether with an over-production of sebaceous matter, and its 
retention in the sebaceous glands, was an important etio- 
logical factor in acne. As the muscles failed to act with 
sufficient vigor, they did not perform one of their offices — the 
emptying of the follicles — and this allowed of the retention 
of glandular products and consequent acne. 

Since the rise of the present dynasty of microorganisms 
a great number of skin diseases have been declared to be 
parasitic. Acne of the pustular variety is one of these, and 
we are told that the pustule is due to the entrance of the 
staphylococcus aureus et albus into the follicles, which offer 
proper ground for its growth. 

Pathology. Acne may begin in the hair follicle or in 
the sebaceous gland, and may be due either to their becom- 
ing clogged up by inspissated sebum and acting like a thorn 
in the flesh, or to their invasion by microorganisms, either 
from without or within, which set up a suppurative peri- 
folliculitis. The papules of acne are located in the upper 
part of the skin, while the pustules are deeper. In very 
bad cases the follicle may be entirely destroyed by the peri- 
folliculitis, and scars will be left. The sebaceous glands 
do not take a very active part in the process. Micro- 
organisms are found abundantly in the suppurating gland 
cavities. 

In acne indurata we find the hair follicle enormously 

1 New York Med. Journ., 1881, xxxiii. 189. 



58 DISEASES OF THE SKIN. 

dilated, its orifice filled with corneous cells, and its cavity 
almost converted into a cyst. The connective tissue about 
the follicle shows decided signs of inflammation, and may 
be increased in amount. Very often the follicle is destroyed 
by the perifollicular inflammation. When the perifollicu- 
litis is severe and extensive, the deep layers of the skin 
become involved and we have abscess formation. 

Diagnosis. Acne is to be differentiated from rosacea, 
papular and pustular eczema, sycosis, the small pustular and 
tubercular syphiloderm, and variola. 

Rosacea is due to a dilatation of the bloodvessels, and is 
attended by hyperemia and telangiectases. If there are 
any pustules they are superficial, and if excised give exit to 
only a drop of pus. Acne is a disease of the sebaceous 
glands, and papules and pustules constitute the disease. 
They are often large, and if excised will give exit to a plug 
of sebaceous matter and thick pus. Rosacea, as a rule, 
occupies the middle third of the face alone, the forehead, 
nose, and chin. Acne is scattered over the whole face, and 
is often found on the shoulders. 

Papular eczema may occur at any age ; acne usually 
occurs between the ages of fifteen and twenty-five. Papular 
eczema rarely is seen on the face alone, and is prone to 
attack the trunk and extremities. Acne often occurs on 
the face alone, and is never disseminated over the limbs and 
trunk. In eczema there is an absence of comedones ; the 
papules are often surmounted by or change into vesicles ; 
they tend to form patches, and the disease is very itchy, so 
that scratch-marks are almost invariably found. When it 
gets well it leaves no trace on the skin. These symptoms 
are foreign to acne. 

In pustular eczema, or what has been called impetigo 
simplex, we have a large number of small pustules running 
together to form patches which rapidly become covered with 
greenish or yellow crusts. The disease runs a far more 
acute and stormy course than does acne, and is itchy. It is 
very frequently met with in children, whom acne rarely 
affects. 

Sycosis is a pustular disease affecting the hair follicles 



ACNE. 59 

alone, each pustule being pierced by a hair. Acne occurs 
on the non-hairy as well as the hairy parts, and, indeed, 
shows preference for regions supplied only with rudimentary 
hairs. 

The small pustular syphiloderm, or syphilitic acne, is a 
general eruption, and it is easy in most cases to obtain other 
evidences of syphilis, such as the remains of the initial lesion, 
enlarged lymphatic glands, mucous patches, or the like. It 
is usually more uniform in its lesions, and these are plainly 
papulo-pustular. The color of the areola is more that of 
raw ham, and less inflammatory -looking than is that of acne. 
The lesions sometimes show a tendency to group into seg- 
ments of circles, and each lesion undergoes a definite devel- 
opment. They sometimes leave small, smooth, white scars 
that may disappear in a few months. The tubercular syph- 
iloderm could be mistaken for an indurated acne. In it 
there will usually be found other evidences of syphilis. The 
lesions group themselves into patches that are kidney-shaped 
or form segments of circles. The tubercles are dark-red 
or raw-ham colored, surrounded by a well-marked areola, 
firm to the touch, and do not contain pus. They may 
ulcerate, or, being absorbed, leave pigmented and punched- 
out cicatrices, and, finally, smooth white scars. The scars 
left by acne indurata are puckered and more disfiguring. 

Variola could scarcely give rise to much doubt, as it has 
well-marked constitutional symptoms, and its lesions undergo 
a definite and characteristic development. 

Treatment. In the treatment of acne we can obtain a 
cure most surely by attention to the general condition of the 
patient ; most rapidly by a combination of internal and local 
treatment. Of course, in cases where only a single pustule 
crops out, as in some women at each menstrual period, there 
is no need for any treatment. But such are not those that 
ask our aid. 

We therefore begin the treatment of a case by a careful 
inquiry into the general condition of the patient, and 
endeavor to regulate any, even the slightest, derangement 
of the internal organs. By so doing we may find no one 
of those conditions enumerated under the etiology of the 



60 DISEASES OF THE SKIN. 

affection, and the patient may consider himself as in the best 
condition. Further observation will probably reveal some 
deviation, though slight, from perfect health. The relief of 
constitutional disorders is conducted according to the prin- 
ciples of general medicine, and cannot be given here. 
Many of the cases require cod-liver oil and iron as general 
measures quite apart from any evident disease. This is 
seen in the sluggish cases occurring in strumous subjects 
with pasty skins. In plethoric subjects with a good deal of 
inflammation attending the acne, laxative agents, such as a 
tenth of a grain of calomel in tablet triturates, given three 
or four times a day, will aid in a cure, quite aside from any 
constipation. 

Diet and hygiene are agents to be employed rather than 
drugs. It is impossible for us to lay down fixed principles 
of diet, and it is better to study each case by itself. The 
well-to-do are all prone to eat too much, and it is remark- 
able how rapidly their acne will improve by reducing their 
diet to the simplest elements. In many of them a milk diet 
for a few days, provided milk agrees with them, will accom- 
plish a marked benefit. It is a good rule to cut off from the 
dietary all pastry, cake, candy, sweets, hot breads and pan- 
cakes, greasy soups, articles fried in fat, rich gravies — in 
fact, all those things that are most apt to tempt the palate. 
Oatmeal is often cited as a cause of acne. Hot water before 
meals, a glass of fluid, either milk or water, at meals, and a 
glass of water two hours after meals is a good direction for 
the use of things to drink. Tea, coffee, malt liquors, sweet 
and heavy wines are to be avoided. Butter may be used 
freely, and care must be had not to restrict too greatly the 
diet. Many young girls almost starve themselves on the 
mistaken idea that a low diet will give them a fine complex- 
ion. Exercise must be insisted on, an hour or more a day 
being spent in walking, horseback or bicycle riding, rowing, 
or other out-door exercise. Daily bathing or dry rubbing 
will keep the skin in healthy condition, and Turkish baths 
are often beneficial. 

Arsenic, sulphide of calcium, glycerin, and ergot are the 
drugs that are given by the mouth as curative in acne. 



ACNE. (31 

Arsenic is the oldest and most honored of these. It is of 
use in only very chronic, sluggish cases, and the more 
papular the case the more useful the arsenic. It should be 
used as the last resort, not as the first. Fowler's solution is 
the most frequently used preparation, in doses of from three 
drops three times a day, as an initial dose, gradually in- 
creased to fifteen or twenty drops or until the appearance of 
some symptoms of poisoning. Piffard 1 recommends bromide 
of arsenic in the dose of yj-g- to -^ grain two or three times 
a day in rather acute cases of acne. A convenient method 
of administration is to make a one per cent, solution in 
alcohol, and give one to two minims of that in a wineglassful 
of water. Should it cause gastric irritation the dose must 
be lessened. I have used this in a number of cases and with 
good results. The sulphide of calcium will be useful in 
many sluggish pustular cases. It should be given in small 
doses, from y^- to y 1 -^ grain, in gelatin-coated pills or fresh 
tablet triturates. One pill may be given four or five times 
a day until the tendency to pustulation is increased. It 
then should be discontinued until the exacerbation has sub- 
sided, when it should be again administered. Grlycerin was 
advocated by Gubler 2 as a cure for acne, and is well spoken 
of by others. It must be given in doses of a teaspoonful 
three times a day increased to a tablespoonful, and is of 
most use in strumous cases. Ergot, either the fluid extract 
in doses of half a drachm three times a day, or a correspond- 
ing amount of ergotin, has many advocates. 

Chrysarobin, internally, has been recommended by Stoc- 
quart, 3 in the dose of one-sixth to one-half a grain. Small 
doses of the bichloride of mercury are sometimes curative 
where there is much infiltration. Sherwell 4 advocates the 
passage of the cold sound through the urethra of a young 
man suffering with acne. 

The objects of local treatment are to open up the pustules 
and papules and allow of the escape of their contents, to 

1 Jo urn. Cutan. and Ven. Dis., 1884, ii. 71. 
'■" Journ. de Bruxelles, 1870. 
3 Annal. Derm, et Syph., 1884, v. 15. 
* Journ. Cutan. and Ven. Dis., 1884, ii. 335. 
4 



62 DISEASES OF THE SKIN. 

stimulate the skin to a more healthful action, and, accord- 
ing to the bacteriologists, to prevent further infection of the 
follicles by micro-organisms. To attain the first two objects 
we may employ either a quick or a slow method; to attain 
the last object we employ an antiparasitic. The best pre- 
ventive local treatment is to keep the skin clean and its 
nutrition good by the use of soap and water. 

The most efficient local treatment for nearly all cases of 
acne is to put the skin somewhat on the stretch, and scrape 
it somewhat roughly with a large and long, blunt dermal 
curette with a fenestrated blade (Fig. 7). This tears off" all 
the tops of the lesions, presses out all the contents of the 
follicles, and stimulates the skin in a most vigorous manner. 
It is followed by some bleeding, which it is well to encour- 
age by the use of warm water. Deep pustules or cutaneous 
abscesses, if not emptied by the curetting, should be incised. 

Fig. 7. 



Fox's ring curette. 

All comedones should be squeezed out. The after-treatment 
consists in washing the face with warm water and soap, and 
dusting with cornstarch, to which may be added oxide of 
zinc. Instead of this, a solution of peroxide of hydrogen 
may be dabbed on. The scraping is to be repeated two or 
three times a week. The procedure seems rough, but after 
the first scraping the patients do not mind it much, and the 
result is the attainment of a smooth skin in a much shorter 
time than by any other method of treatment. With this 
plan we may use a sulphur ointment, a drachm to the ounce, 
to be applied twenty-four hours after the scraping, or a wash 
of bichloride of mercury, one-half grain to the ounce of 
dilute alcohol, to which may be added a little glycerin. 
Thus will we fulfil all three of the indications for treatment. 
The same results can be attained in a slower way by 
opening every pustule with an acne lancet (Fig. 8), and 
squeezing out every comedo. This is to be done once or 



ACNE. 63 

twice a week, and a sulphur preparation used between times. 
Very timid patients who will allow no surgical interference 
may be treated according to the same principles by direct- 
ing them to scrub their faces thoroughly once a day with 
green soap, or tincture of green soap, and leave the lather 
on. After a day or two of good scrubbing an amount of 
dermatitis will be excited sufficient to cause the old skin to 
peel off, while the tops of many of the lesions will have 
been torn off, and the skin will have been decidedly stimu- 
lated. Not until the skin has become scaly and feels tense 

Fig. 8. 



Fox's acne lance and dermal curette. 

to the patient should a soothing ointment be applied. 
Repeated applications of the soap frictions will slowly 
bring about improvement. Rubbing the face with fine 
sand or coarse cornmeal will do good, but is not so ele- 
gant. 

Massage to the skin should be practised. The tips of the 
fingers should be dipped in cold cream, and then pressure 
being exerted by them the skin of the forehead should be 
deeply stroked from the middle line out and over the tem- 
ples. The nose should be stroked from the bridge outward 
and downward. The skin of the cheeks should be pinched 
up and rolled between the fingers and thumb. These move- 
ments facilitate the emptying of the follicles. The appli- 
cation of the galvanic current by means of the roller elec- 
trode, or by ordinary sponge electrodes, will in some sluggish 
cases prove helpful. 

A vast number of prescriptions have been written which 
are " good for acne," the majority of which contain sulphur 
in some form, and in the strength of. half a drachm to one 
drachm to the ounce, and in ointment or lotion form. Sul- 
phur in powder form is good if the patient doesn't mind 
the odor. The ordinary sulphur ointment of the Pharma- 
copoeia diluted one-third or one-half is as good a prepara- 



64 DISEASES OF THE SKIN. 

tion as any. It may be made more elegant by adding some 
perfume. The sulphuret of potassium may be used in the 
following : 



R . Potass, sulphurat., ) - - o 

Zinci sulphat, J ™J > 

Aquse rosae, ^iv; 100 



M. 



This preparation is commonly spoken of as " Lotio alba," 
and is one of the most useful of the compounds of sulphur. 
It is to be applied every day after being well shaken. 

Vleminckx's solution is an active preparation in causing 
the old skin to exfoliate. It is composed of — 



J&. Calcis, 


3ss; 


15 


Sulph. sublim. , 


Ij; 


30 


Aquse destil., 


3 x ; 


300 


Cook to 3f vj. and filter. 







M. 



After this has been left on a few hours, it must be washed 
off and a soothing ointment, such as ungt. zinci oxid., or 
ungt. aquae rosse, applied. It is most useful in acne of the 
back. 

Mercurial preparations may be used to more advantage 
in some cases than those of sulphur. It must be borne in 
mind that a mercurial must never be applied to the skin 
until all traces of sulphur are removed, or vice versa, be- 
cause if the precaution is forgotten, the black sulphide of 
mercury will be formed, which will give the skin the appear- 
ance of being sown with powder-grains. A lotion of corro- 
sive sublimate, 1 in 1000 to 2000, may be mopped on once 
or twice a day. Or an ointment of the protiodide, as recom- 
mended by Duhring, may be used : 



R. Hydrarg. pro tiodid., gr. v-xv; 1 

Hydrarg. ammon., gr. x-xxx; 2 

Ungt. simplicis, ,^j ; 30 

Lassar 1 recommends the following paste : 



M. 



Be . /3-naphtol, 10 parts. 

Sulphur precip., 50 " 

Vaseline 1 &ft 25 « M 

Sapo viridis, J 

1 Therap. Monatshft,, 1887, No. 1. 



ACNE. 65 

This is to be spread upon the skin to the thickness of the 
back of a knife-blade, and left on for fifteen or twenty 
minutes. It is then to be wiped off with a soft cloth, and 
the skin powdered with talc. The skin becomes inflamed, 
turns brown, and peels off. The application is to be re- 
peated every day until the skin does peel off. Desquama- 
tion can be hastened by the application of Lassar's paste 
with two per cent, of salicylic acid. 

Resorcin has been commended, used in twenty per cent, 
strength. Ichthyol, the ammonio-sulphate, is recommended 
by Unna for acne, either as a three to five per cent, oint- 
ment or a three to ten per cent, aqueous solution. As much 
as fifteen grains of it is to be taken by the mouth during 
the day. A mild corrosive sublimate wash is to be applied to 
the face until the patient goes to bed, and then a ten per 
cent, aqueous solution, or paste of ichthyol, is to be kept on 
till morning. Startin 1 has employed local steam baths by 
means of a steam atomizer, with success. The steaming 
should be kept up for twenty or thirty minutes, and tincture 
of benzoin used in the medicine cup. While useful in some 
cases it does harm in other cases. 

The foregoing remedies are all specially adapted to more 
or less sluggish cases, the type met with in the great ma- 
jority of instances. In very recent and quite inflamma- 
tory cases, besides the administration of laxatives and the 
regulation of the diet, the patient should be directed to 
bathe the face in hot water either with or without the addi- 
tion of borax (5ij to Oj), and apply a soothing ointment. 

Bathing of the face with hot water before the application 
of any lotion or ointment should be advised. In indurated 
acne, where cutaneous abscesses have formed, and the 
lesions are discrete, each abscess will have to be opened up 
with a lance, the contents of the abscess discharged, and 
carbolic acid, either pure or diluted, introduced, by means 
of a little cotton around the end of a bit of wood, into the 
abscess-cavity, so as to destroy the lining membrane. 

Individual acne lesions can sometimes be aborted by 

1 Lancet, 1889, i. 934. 



66 DISEASES OF THE SKIN. 

touching them with pure carbolic acid, or acid nitrate of 
mercury. 

Prognosis. By persistent effort, and careful regulation 
of all the bodily functions, a great improvement can be 
effected, one fairly deserving of the name of cure. But it 
is often hard to prevent the occasional appearance of a few 
acne lesions until the period of life in which acne usually 
occurs is passed. There are some rare cases in which we 
can do nothing, because we are unable to remove the under- 
lying cause. 

Acne Adenoid. See Lupus Miliaris. 
Acne Albida. See Milium. 

Acne Artificialis. By this term is meant an inflamma- 
tion of the sebaceous glands and hair follicles caused by 
drugs either applied locally or acting from within. It has 
three principal varieties, namely, tar acne, bromic acne, 
and iodic acne, and should be regarded rather as a derma- 
titis medicamentosa than as an acne. Tar produces acne- 
like lesions with black points when applied locally to some 
susceptible skins. As a rule, papules are more abundant 
than pustules, but abscesses and furuncles may form. These 
lesions are not confined to the usual locations for acne, are 
particularly abundant on the extensor surface of the arms, 
and are recognizable by their central black points, and by 
the fact that the patient is using tar. For its cure all that 
is necessary is to stop the use of the tar, and to soothe the 
inflamed skin. None of these acnes is a true acne. Bromic 
and iodic acne will be spoken of under Drug eruptions. 
Derivatives of tar, chrysarobin, and pyrogallol may also 
produce similar acne-like lesions when applied externally. 

Acne Atrophica is a term applied to the scars left by 
acne, and to acne frontalis. The first needs no description. 
The other will be found further on. 

Acne Cachecticorum is rather to be regarded as a scrof- 
uloderm than an acne, as it probably has little to do with 
the sebaceous glands. It occurs in broken-down or scrof- 
ulous subjects, and is particularly prone to appear upon 
the extremities. It takes the form of small, congested, or 



ACNE. 67 

dark-red, sluggish papules and papulo-pustules that run a 
slow course, break down, perhaps ulcerate, and leave small 
depressed cicatrices. Occurring on the fingers, these will 
often be congested and clubbed. It is one of the rare forms 
of the disease, and requires tonic remedies such as cod-liver 
oil and iron for its cure. 

Acne Cornea. See Keratosis follicularis. 
Acne Fluente. See Seborrhoea oleosa. 

Acne Frontalis. Synonyms : Acne rodens ; a. ulcereuse ; 
a. atrophique ; a. arthritique ; a. miliare scrofuleuse; a. vari- 
oliformis of the Germans ; a. necrotica ; a. pilaris, lupoid acne. 

Acne frontalis is the name given by Boeck to an acne- 
form lesion that occurs in adults on the forehead along the 
line of the hair. It is also met with on the cheeks and 
nose, and some lesions may be on the scalp. It has been 
described as occurring upon the trunk, sternal region, and 
back. The eruption consists of pinhead- to lentil-sized, 
reddish-brown, hard papules, on which form flaccid pustules 
that soon dry into a brown crust. If on hairy regions, the 
crust may be pierced by a hair. Some papules have an 
inflammatory halo around them. The crust adheres very 
closely, and seems as if sunk into the papule. If removed, 
a loss of substance is revealed. It is possible to press out 
a drop of pus from under old lesions just about ripe enough 
to lose their crusts. When the crust falls of itself it leaves 
a brownish-red cicatrix that gradually grows white. Some- 
times the lesions are present in large numbers, and as each 
one runs a slow course, lesions in all stages of development 
will be found. 

This is a rare form of disease, and its etiology and path- 
ology are still undetermined. It bears a decided resemblance 
to syphilis in some of its forms. It is probable that some 
of the cases that have yielded to mercurial ointments were 
syphilitic. It runs a very chronic course, sometimes lasting 
for years. 

Treatment. In treatment sulphur ointment or a mer- 
curial will probably give the best results. Curetting is also 
of great service. 



G8 DISEASES OF THE SKIN. 

Acne Hypertrophica. See Rosacea. 

Acne Iodic and Brornic. See Dermatitis medicamentosa. 

Acne Keloid. See Dermatitis papillaris capillitii. 

Acne Mendicamentosa. See Acne iodic and brornic. 

Acne Mentagra. See Sycosis. 

Acne Miliaris. See Milium. 

Acne Necrotica. See Acne frontalis. 

Acne Pilaris. See Acne frontalis. 

Acne Rodens. See Acne frontalis. 

Acne Rosacea. See Rosacea. 

Acne Scrofulosorum. See Acne cachecticorum. 

Acne Sebacea. See Seborrhoea. 

Acne Syphilitica. See Pustular syphiloderm. 

Acne Tnberculoide, or Tuberculeuse Ombiliquee. See 

Molluscum contagiosum. 

Acne Ulcereuse. See Acne frontalis. 

Acne Varioliformis. See Molluscum contagiosum and 
Acne frontalis. 

Acrochordon (A 2 k-ro-ko 2 rd r -o 2 n). See Fibroma. The 
term is also applied to large or small polypoid prominences 
produced by an overgrowth of the endothelium of the seba- 
ceous glands. These occur in elderly people upon the eye- 
lids, neck, and throat. They may attain the size of hazel- 
nuts, and look like overgrown milia. The treatment consists 
in removing tbem by ligature or scissors. 

Acrodynia (A 2 k-ro-di 2 n'-i 2 -a 3 ) is a disease closely allied 
to pellagra in its symptoms, that has been observed chiefly 
amongst the French and Belgian soldiers, and is probably 
due to some defect in food-supplies. It begins with gastro- 
intestinal irritation to which certain neuroses soon add 
themselves, such as formication, hyperesthesia and anaes- 
thesia. An erythema of the hands and feet, and may be 
of the whole body, followed by brown or black pigmenta- 
tion, is the cutaneous element of the disease. Recovery 
usually takes place, though death may occur from diarrhoea. 



ADENOMA. 69 

Acromegaly (A 2 k-ro'me 2 g-a 2 l-i 2 ). A disease character- 
ized by overgrowth of the bones and soft tissues of the face, 
hands, wrists, and feet. It is a rare condition and is allied 
to elephantiasis. It is a progressive and, usually, symmet- 
rical disease, and at times attains immense proportions. 
The skin becomes dry and harsh, yellowish, and wrinkled. 
Fibromata may develop. Symptoms of nervous derange- 
ment are also present. The cause is unknown, and treat- 
ment of no avail. 

Actinomycosis (A 2 k-ti 2 n-o-mi-ko r si 2 s). While this is 
usually a disease of cattle, in which it causes tumors of 
the jaws, it may attack man and produce nodular tumors, 
with fistulous openings. It is due to the invasion of the 
tissues by the ray fungus. Infection usually occurs by the 
mouth along a carious tooth, but it may take place through 
the digestive tract, the lungs, and, rarely, by an abrasion 
on the skin. The tumors bear a strong resemblance to sar- 
coma and are livid or bluish-red. At first firm, they, after 
a time, soften and break down and discharge through a fis- 
tulous tract ; at first a purulent, afterward a sanious material, 
in which are numerous yellow granules, from pinhead to 
hemp-seed size. It runs a chronic course. Its prognosis 
is bad, and surgical treatment is the only possible curative 
agent. 

Addison's Keloid. See Morphoea. 

Adeno-carcinoma is a carcinoma originating in the glands 
of the skin ; most often in the sweat glands. 

Adenoma (A 2 d-e 2 n-o'ma 3 ). These are glandular tumors, 
and are due to a proliferation of the lining cells of either 
the sebaceous or sweat glands. There are therefore two 
varieties : A. sebaceum and A. sudoriferum. Though met 
with in persons of mature years, it is not improbable that 
they are congenital defects. They form solid tumors from 
pinhead to egg size or larger. They may remain stationary 
or grow ) may disappear spontaneously, ulcerate, form cysts, 
or undergo hyaline, colloid, or fatty degeneration. While 
usually benign, they may become malignant. They tend to 
relapse after extirpation. 

4* 



70 DISEASES OF THE SK1K 

The sebaceous form is encountered most often on the 
face, about the nose and mouth ; less frequently upon the 
scalp, but may occur anywhere. Their color varies from 
pale yellow to red, when they will have fine telangiectases 
over them. They occur most often in females, are generally 
multiple, often with an uneven surface, and seated deep in 
the skin. Pollitzer has cured one case of the sebaceous 
variety by means of multiple scarifications. 

The sudoriferous variety occurs as dirty grayish-white 
tumors, sometimes in groups, with uneven, often knobby 
surface. They are rare lesions of the skin, difficult of 
diagnosis, and require extirpation or total destruction for 
their cure. 

Ainhum is a disease most frequently seen in the negro 
race, though a number of cases have been reported from 
India. It is seen in men more often than women, and 
several members of the same family have been known to be 
affected by it. The little toe, of one or both feet, is the one 
usually diseased, though the other toes do not always 
escape. It begins as a furrow on the inner and lower side 
of the proximal end of the toe, which gradually extends 
outward and upward so as to encircle the whole toe at its 
juncture with the foot. In the meantime the toe becomes 
enlarged, separates from its next neighbor, and rotates 
outward. When fully developed the toe wobbles about so 
that it interferes with walking. The whole process is un- 
attended with ulceration except accidentally caused, and 
after the disease has lasted a long time. When it sets in 
the toe falls off. There is little pain experienced till near 
the end of the disease. It takes from one to ten years for 
the full development of the disease. The cause is unknown. 
The process is one of progressive degeneration and destruc- 
tion of all the elements of the toe ; skin, muscles, bone. 
Amputation is required for the cure, and healing takes 
place rapidly. 

Albinism. See Leucoderma. 

Aleppo Boil, Aleppo bouton, or Aleppo evil, is an ill-de- 
fined furuncular disease occurring in Syria and the Levant. 



ALOPECIA SENILIS. 71 

Algidite Progressive. See Sclerema neonatorum. 

Algor Progressivus. See Sclerema neonatorum. 

Alopecia (A 2 l-o-pe r slii 2 -a 3 ). Synonyms : Calvities ; (Fr.) 
Alopecie ; (Ger.) Kalilheit ; (Ital.) Calvezza ; (Sp.) Calvez ; 
Baldness. 

By alopecia is meant a partial or general loss of the 
hair, so as to produce a noticeable thinning or a bare spot. 
There are four main varieties, namely, Alopecia adnata ; 
Alopecia senilis ; Alopecia prematura or presenilis ; and 
Alopecia areata. 

Alopecia Adnata is congenital baldness, and is a rare 
affection. 

Symptoms. The newborn child is covered with long 
dark hair which soon falls to give place to fine lanugo hairs; 
or this change has taken place before birth, the usual course 
of events, and at birth lanugo hairs only are present. In 
alopecia adnata there is not the slightest trace even of 
lanugo hairs either on the scalp or eyebrows. In some 
cases the baldness is not so complete. Most cases, after 
months or years, recover either altogether or partially, but 
in some cases the hair never grows. In pronounced cases 
delayed dentition or deficiency of the teeth has been observed. 

Etiology. The cause of the disease is arrest of the 
development of the hair, probably due to an error in inner- 
vation. It is said to be hereditary in some families. 

Treatment. The treatment is mainly an expectant one. 
The nutrition of the child should be looked after, and the 
scalp kept in a healthy condition. If this expectant plan 
does not satisfy the child's attendants, some of the stimulat- 
ing hair washes, as in alopecia presenilis, may be prescribed 
for the moral effect upon them. 

Alopecia Senilis is baldness occurring in advancing years. 
Any loss of hair commencing about the forty-fifth year and 
without any apparent cause may be placed under this head- 
ing. Graying of the hair may have preceeded it for several 
years or may be coincident with it. Or the hair may fall 
without becoming gray. The hair fall having once begun 
is progressive, though its rate of progress may be slow or fast. 



72 DISEASES OF THE SKIN. 

It usually shows itself first upon the vertex of the head, 
forming the tonsure, which slowly increases in size, and, 
moving forward, renders the whole top of the head bald. 
Or it may begin anteriorly and move backward. Or the 
hair on the whole top of the head may become thinned at 
once. Rarely are the temporal and occipital regions bald, 
and an island or tuft of hair is sometimes preserved for a 
long time in the middle frontal region. The hair fall is 
always symmetrical, and the bare scalp is smooth, oily, 
shiny, and appears as if stretched. Not only does the hair 
fall from the scalp, but it may fall from the axillae and pubic 
region ; these manifestations I believe to be more common 
in women than men. Very rarely does the beard fall. 

Etiology. The cause of this form of baldness is a pro- 
gressive atrophy of the scalp. Men are far more prone to 
the disease than are women. 

Tkeatment. As to the treatment, we can do nothing. 
Prophylaxis, as described under Alopecia prematura, will 
delay its onset. 

Alopecia Prematura is baldness occurring before middle 
life. It may be idiopathic or symptomatic. 

Alopecia prematura idiopathica arises without any evi- 
dent disease of the scalp or disorder of the general health. 
]t usually begins in early life, between twenty-five and 
thirty-five ; it may begin as early as the eighteenth year. 
Its general course is the same as the senile form of alopecia. 
Very often the upper parts of the temples are earliest 
affected, the hair line receding. In those who part the hair 
in the middle, the thinning of the hair about the part may 
be the first thing to attract attention. The process of the 
hair fall is one of progressive thinning of the individual 
hairs at first, and then of the whole quantity of hair, so 
that strong hairs give place to lanugo hairs, and these in turn 
fall and leave bald places. At the same time a progressive 
tightening of the scalp upon the skull will be observable in 
some cases, the scalp having lost that cushion of fat that is 
under it in early life. The hair fall having begun is pro- 
gressive, though years may elapse before there is absolute 



ALOPECIA. 73 

baldness. The tonsure may not enlarge for a long time, 
and then increase rapidly in size. 

Etiology. The main cause of this form of baldness is 
heredity. Fathers and sons for generations may grow bald 
early, or the inherited peculiarity may have to be traced 
to the grandparents or some collateral line. Not all the 
children of one family in which baldness is hereditary are 
bald, but it will manifest itself in two or three of the chil- 
dren. According to Pincus, 1 inheritance and chronic eczema 
or an impetiginous eruption on the scalp in the years pre- 
ceding puberty are the only predisposing causes of bald- 
ness. Insufficient or improper care of the scalp ; daily 
sousing of the hair with water, combined with improper 
drying of the hair afterward ; sweating of the head, either 
spontaneously or on account of the wearing of unventilated 
or hot head-coverings ; constant mental strain, either on 
account of intellectual work or of worry ; the wearing of 
stiff, unyielding hats ; gout ; and dissipation, are all put 
forth by reputable observers as causes of premature baldness. 

That women are less often bald than men probably de- 
pends upon several factors: The fatty cushion beneath 
their scalps is longer preserved than in men ; they give more 
attention to the care of the hair and less often wet it ; and 
their hats are soft, ventilated, and fit loosely. 

Treatment. We can do more for this form of baldness 
by prophylaxis than by attempts at making the hair that 
has fallen out grow in again. Prophylaxis should begin at 
the beginning of life, and should be continuous. This is of 
special importance in the case of children in families prone 
to early loss of hair. 

The hygiene of the scalp is the chief part of the prophy- 
lactic treatment. Beginning at infancy, the scalp should 
be gently cleansed of the vernix caseosa and other extra- 
neous substances that have gathered on it during the process 
of parturition. This should be done by the gentle use of 
soap and water after rubbing in a little sweet almond or 
other bland oil. No force should be used, and after the 

1 Virchow's Archiv, 1867, xli. 322. 



74 DISEASES OF THE SKIN. 

scalp is washed it should be patted dry with a soft warm 
cloth, and a little oil or vaseline smeared over it. After 
the first washing it should be oiled daily and washed every 
second day. When the hair begins to grow a soft brush 
alone should be used to arrange it, and the daily oiling 
may be stopped unless sebaceous matter accumulates in 
cakes, in which event the oiling should be continued. 
Sometimes it is well to add a little sulphur to the oil or 
vaseline, but in most cases it is unnecessary. The slightest 
indication of disease of the scalp should be promptly and 
properly dealt with. A child's hair should be cut short, 
not cropped close to the head. After a girl has reached her 
eighth or ninth year, the hair should be allowed to grow. 

The hair and scalp do not need to be washed more than 
once in two or three weeks, and for this purpose any good 
soap will do, with plenty of water to wash out the soapsuds. 
Borax with water will clean the scalp nicely, but its con- 
tinuous use is injurious. The yolk of three eggs beaten up 
with lime-water makes an elegant shampoo. The daily sous- 
ing of the head in water should be prohibited. Deep 
brushing of the hair with a long-bristled brush of sufficient 
stiffness to warm, but not scratch the scalp, is one of the 
best agents we have for stimulating the scalp. The brush- 
ing should be done daily and systematically. 

Pomades and hair washes should be avoided unless there 
is some evident disease of the scalp. Women should be 
cautioned against pulling their hair into artificial and con- 
strained positions. Most important of all is it that a suf- 
ficient amount of outdoor exercise should be taken to aid in 
keeping the patient in good general condition. 

When the hair has begun to fall it is important that the 
hygiene of the scalp should be begun, if not already prac- 
tised. We can do more for our cases in this way than by 
any other method. 

Many remedies have been advised for the curative treat- 
ment of baldness. Pilocarpine, in hypodermic injections or 
in ointment form, has been warmly commended. Lassar 1 
prescribes it as follows : 

1 Therap. Monatsheft, 1888, No. 12. 



ALOPECIA. 75 



1& . Hydroclilorate of pilocarpine, gr. xxx ; 2 

Vaseline, Zv; 20 

Lanolin, % ij ; 60 
Oil of lavender, gtt. xxv. 



M. 



He also advises oil of turpentine, equal parts with an 
indifferent oil or alcohol. It is my experience that most of 
these cases do better with oily than with alcoholic prepara- 
tions. Gallic acid, 3 per cent., in an oily excipient ; tar; 
galvanism ; massage; tincture of cantharides (3j-oj); tinc- 
ture of nux vomica (3J-5J) ; and a lot of other irritants and 
essential oils, have their advocates. My experience teaches 
me that so-called " hair tonics " are of little value, and that 
the best remedies are attention to the general health of the 
patient, massage to the scalp, and daily, systematic, and 
deep brushing of the hair. 

Prognosis. The prognosis of this form of baldness is 
bad, and especially so if the disease is hereditary and the 
patient is more than thirty years of age. It is better with 
women than with men, as they will give more time to the 
care of their scalps, and show less tendency to alopecia. 

Alopecia prematura symptomatica is premature bald- 
ness in which there is some evident disease of the scalp, 
or disorder of the general nutrition of the body, to account 
for it. It has four varieties : Alopecia furfuracea seu pity- 
rodes ; A. syphilitica ; Defluvium capillorum ; and A. fol- 
licularis. 

Alopecia Furfuracea seu Pityrodes is the form most fre- 
quently met with, and the one in which we can often obtain 
good results by treatment. 

Symptoms. In it we have an evident disease of the scalp 
to deal with — that is, dandruff. By this we mean either a 
seborrhoea with fatty crusts, or else a pityriasis with more 
or less abundant scaling. Unna regards both conditions as 
being simply different forms of one disease that he calls 
eczema seborrhoicum. 

Alopecia pityrodes has two stages : The first one lasts 
from two to seven years or more, and is attended by a 
greater or less amount of dandruff and by dryness of the 
hair. Then comes the second stage, when the hair falls 



76 DISEASES OF THE SKIN. 

more or less rapidly. Its course may be the same as that 
of the two previously described forms of baldness, though 
more commonly the whole top of the head is affected at 
once, the hair becoming progressively thinner in diameter 
and less in amount until baldness results. As the baldness 
increases the dandruff lessens. The disease is one of early 
life in a large number of cases, often occurring between the 
twentieth and thirtieth year, and affects both sexes. 

Etiology. The cause of the hair fall is the dandruff. 
By this it is not meant that everyone who has dandruff will 
become bald. Everyone's experience is against that. But 
it is true that in certain persons when, on account of some 
error in the nutrition of the sebaceous glands, they become 
diseased, the hair follicles sympathize with them, and after 
a time the hair production ceases. Of late, the opinion is 
gaining ground that alopecia pityrodes is contagious, and 
the experiments of Lassar and Bishop 1 would seem to prove 
this. They succeeded in producing typical alopecia pity- 
rodes in guinea-pigs by rubbing into their backs a pomade 
composed of the scales taken from the head of a student who 
was afflicted with the same disease. A number of observers 
have reported from time to time the finding of a parasite in 
this disease, but as yet no one microorganism can be demon- 
strated as positively at the bottom of the trouble. 

Treatment. The treatment of this form of baldness must 
be addressed to the cure of the seborrhoea or pityriasis that 
causes the loss of hair. Prophylaxis is here again more 
important than the use of remedies for promoting the growth 
of the hair. The treatment of seborrhoea and pityriasis 
will be considered under their respective headings, and need 
not be here detailed. My belief is that oily applications 
are better than those containing alcohol. The mistake is 
frequently made of prescribing tincture of cantharides or 
other irritant because the hair falls. Of course, these 
things, in an already more or less inflamed sealp, only do 
harm. If we can succeed in curing the seborrhoea, the 
hair will take care of itself. If the case comes to us before 

1 Monatshefte f. prakt. Dermat.> 1882, i. 131. 



ALOPECIA. 77 

absolute baldness is established we can feel pretty confident 
that we can stop, or at least delay, the fall of the hair. But 
we must inform our patients that it is only by long and 
persistent treatment that we can accomplish anything. 

Lassar's plan of treatment has gained great currency, 
and is as follows : The scalp is to be vigorously washed each 
day with a tar soap that forms plenty of suds. The soap- 
suds are to be washed out with warm, followed by cold 
water, the scalp dried and anointed with equal parts of a 
half per cent, solution of bichloride of mercury, glycerin, 
and cologne water. This is to be dried out by applying a 
half per cent, solution of /3-naphtol in absolute alcohol. 
Finally, an oil made up of 



JjL Ac. salicylici, 3 iv ; 10 

Tincture of benzoin, gr. xl ; 3 

Neat's-foot oil, g iij ; 100 



M. 



is to be applied. The procedure is to be kept up for six to 
eight weeks. I have found few patients who would persist 
in it, and in these I have seen little good result. For 
women it is impracticable. 

Resorcin has been commended. It may be prescribed as 
follows : 



H 



Resorcin pura, 


gr.xv; 


3 


01. ricini, 


gss; 


6 


Spts. vini rect., 


ad Ij; 


100 


Bals. Peruv., 


gtt. ij. 





M. 



Tar is a good remedy, but it is objectionable on account 
of its odor and color. /3-naphtol, in 5 to 10 per cent, 
strength, and hydrate of chloral in about the same strength, 
maybe tried. Sulphur is the most reliable remedy. Further 
particulars in regard to the treatment of the seborrhoea will 
be found under the section upon that subject. When there 
is absolute baldness, it is questionable if anything will make 
the hair grow. 

Alopecia Syphilitica may be an early or late manifes- 
tation of syphilis ; it occurs both in benign and malignant 
cases, and manifests itself as a more or less general and 



78 DISEASES OF THE SKIN. 

temporary hair fall, or as a localized, destructive, and per- 
manent one. 

Symptoms. The former variety occurs early in the dis- 
ease, and is a thinning of the hair in irregularly shaped 
patches scattered over the scalp, giving to it an appearance 
similar to what would be produced by cutting the hair care- 
lessly with a dull pair of shears. In rare cases we may have 
a general loss of hair from all hairy regions. The broken 
arch of the eyebrow is always suggestive of syphilis. There 
may be some seborrhoea with this form of alopecia. 

Localized baldness is one of the later manifestations of 
syphilis, and is always preceded by a destructive disease of 
the scalp. The bald spots will vary in size with the extent 
of the destructive process, which may be one of absorption 
or ulceration. 

Diagnosis. The diagnosis of syphilitic alopecia is made 
by observing the irregular shape of the patches, and that 
they are not completely bald ; and by the occurrence of the 
broken arch of the eyebrow. These should arouse suspicion, 
when other symptoms of the disease will be found. It most 
resembles alopecia areata, but in this disease the patches are 
perfectly circular or oval, and entirely bald. 

The baldness due to destructive forms of syphilis can be 
confounded only with that of favus. In the latter disease, 
the scalp preserves a reddish color for a long time, and then 
assumes an atrophic, smooth, cicatricial look which is char- 
acteristic of it. The history of the two cases is very dif- 
ferent, as in favus we do not have ulceration, and we do 
have cupped, sulphur-yellow crusts. Favus is also more 
widespread and disseminated than is late syphilis of the 
scalp. 

Treatment. The treatment of this form of baldness is 
that of the underlying disease. A mercurial ointment or 
an oil containing the bichloride may aid in hastening the 
new growth of the hair in the early form of baldness. The 
late form may be lessened by active constitutional and local 
treatment, according to the general principles laid down for 
the management of syphilis. 



ALOPECIA. 79 

The variety called Defluvium Capillorum is that sudden 
and general fall and manifest thinning of the hair which 
comes on during or after some severe illness, such as partu- 
rition, fevers, mercurialism, and various cachexia. 

Symptoms. Rarely does it produce complete baldness. 
The fall is usually rapid, and takes place during convales- 
cence or after recovery, rather than during the course of 
the disease. Seborrhoea may or may not be present. 

Etiology. The cause of the hair fail is the profound 
disturbance of the nutrition of the body, in which the hair 
sympathizes. 

Treatment. The treatment is rather to be addressed to 
the patient than to the hair. If we can succeed in building 
up the patient's strength, the hair will take care of itself. 
Local treatment is the same as in alopecia pityrodes. 

Alopecia Follicularis is baldness due to some disease ot 
the scalp that either destroys the hair follicles or impairs the 
proper performance of their function. A history of the caus- 
ative disease may be obtained, or the disease itself will be 
present. Impetigo, long-continued sycosis, inflammatory 
diseases such as erysipelas, parasitic diseases such as favus 
and ringworm, and destructive new growths such as syphilis 
and lupus, all may cause alopecia follicularis. 

The etiology, diagnosis, prognosis, and treatment of this 
form of baldness are the same as the disease that gives rise 
to it, for which we must refer to the proper sections. 

Alopecia Areata. Synonyms: Area celsi ; Area occiden- 
tals diffluens, seu serpens, seu tyria; Alopecia circumscripta ; 
Porrigo seu tinea decalvans ; Vitiligo capitis ; Ophiasis ; 
Phyto-alopecia ; (Fr.) Teigne pelade ; Pelade ; (Ger.) Die 
kreisfleckige Kahlheit ; Circumscribed baldness. 

This form of baldness usually begins suddenly, the patient 
discovering by accident, or being told by someone, that he 
has a bald spot. Sometimes, on waking in the morning, the 
patient is astonished to find loose hairs in his bed and, on 
looking in the glass, to see that he has a bald patch on his 
head. In some cases the hair fall may have been preceded 
for days or weeks by neuralgic pains in the head. In most 



80 



DISEASES OF THE SKIN. 



people there are no premonitory symptoms, and apart from 
the bald spots no discomfort on the part of the patient, nor 
cutaneous lesions. The neuralgia may continue after the 
hair fall, or it may cease. There may be but one bald patch 
or there may be a dozen patches. A patch may be as small 
as a three-cent silver piece or as large as a silver dollar. If 
larger — and the whole head may be completely bereft of 
hair — the patch is formed by the coalescence of several 



Fig. 9. 




Alopecia areata. 

smaller ones. A patch may attain its full size at once, or 
it may slowly enlarge, spreading at the periphery. The 
patches are more or less perfectly oval or circular in shape, 
and sharply defined against the surrounding hair. Patches 
formed by the coalescence of other patches lose the oval 
outline, and may have a scalloped border. The color is 
usually that of the normal scalp ; it may be pale or hyper- 
semic. The patch is perfectly bare and smooth, without 
scales, as a rule. Sometimes it is dotted over with short, 
broken hairs, old roots that soon fall out. Sometimes it 
looks as if it were depressed, an appearance due to falling 
out of the hair roots. Any or all the hairy regions of the 



ALOPECIA. 81 

body may be affected, the patient sometimes being entirely 
denuded of hair. Most often it is the scalp that suffers, 
especially the temporal and occipital regions. Around the 
border of a recent patch the hair is loosened so that it may 
be readily extracted. The sensibility of the skin may be 
diminished. Generally it is preserved. 

The course of the disease is chronic, with a strong ten- 
dency to spontaneous recovery in anywhere from three 
months to several years. Recovery is heralded by the 
growth of a fine down upon the bald patch. This will fall 
out and be replaced by lanugo hairs that in their turn will 
fall out to be replaced by stronger hairs, until normal hairs 
will grow at last, though these at first may be white. Some 
cases relapse year after year ; in some cases the hair never 
grows beyond the lanugo stage ; and some cases remain 
permanently bald. 

Etiology. The subjects of the disease may be in appar- 
ently perfect health, but not infrequently they are of very 
nervous temperament, exhausted by overwork or nervous 
strain, or out of health in some way. Both sexes are 
affected, the male sex rather more than the female. It 
occurs very often in children. Thus Crocker, who has a 
large experience with children, met with it in children 
under twelve years old thirty- seven times out of eighty-three 
cases. The youngest case reported was at two years of age, 
and cases have been seen as late as in the sixtieth vear. It 
is rather more frequent among the poor than among the 
well-to-do. It is more frequent in some countries than in 
others. Thus Crocker's tables show that in London it forms 
two per cent, of all skin cases ; Bulkley's tables show but a 
little more than one-half of one per cent, in New York. 

The disputed points in the etiology of alopecia areata are 
its contagiousness, and whether it is a neurosis or a parasitic 
disease. At the present time it is impossible to decide with 
absolute certainty which of the contending parties is right. 
Most instances of contagion have been reported by French 
observers whose diagnostic skill we can hardly call in ques- 
tion. They have reported instances in which a large num- 
ber of cases have appeared in barracks or schools, and from 



82 DISEASES OF THE SKIN. 

there spread to neighboring towns. In England similar 
apparent epidemics have been reported, but as a fungus 
indistinguishable from the trichophyton fungus was found 
in the surrounding hairs, they were doubtless instances of 
bald ringworm. It is possible that the French epidemics 
were of similar character. In this country one epidemic 
of apparently alopecia areata has been reported by Putnam. 1 
The cases were examined bv Drs. J. C. White and J. T. 
Bowen, of Boston, who agreed in the diagnosis. Nothing sug- 
gestive of trichophytosis was found. Certainly the body of 
experience is against the contagiousness of the disease. Bes- 
nier and Doyon, 2 who believe firmly that the disease is con- 
tagious, think that it is transmitted most often by means of 
the barber's utensils, and that it is impossible in a great 
number of cases to trace the contagion. Hutchinson and some 
other English authorities are inclined to the belief that in 
many cases ringworm preceded the appearance of the bald 
spots at a greater or less interval. 

As to the parasitic origin of the hair fall, it is not yet 
proven. A goodly number of skilled microscopists have 
described the fungus, but they do not agree amongst them- 
selves, and so we are justified as regarding the question as 
unsettled. 

This leaves only the neurotic theory, and by the majority 
of dermatologists the disease is believed to be a tropho- 
neurosis. It has been known to follow blows or injuries to 
the head, moral or mental shock, operation on the neck, 
and, experimentally, by injury to or extirpation of the second 
cervical ganglion in cats. 

Pathology. Though hairs taken from the margin of an 
advancing area show atrophic changes, there is nothing dis- 
tinctive about such changes. The most exhaustive study of 
the disease of recent date is that of A. R. Bobinson. 3 He 
found evidences of inflammation, and some round-cell infil- 
tration confined principally to the perivascular region. In 

1 Archiv. Pediat, 1892, ix. p. 595. 

2 Path, et Trait des Mai. de la Peau : Kaposi, French edition, 
Paris, 1891. 

3 Monatshefte f- prakt. Dermat., 1888, vii. 409, 



ALOPECIA. 83 

recent cases there was a coagulation of lymph in many 
lymphatics, and of fibrin in a few of the large and small 
arteries, with, in old cases, a thickening of their walls. In 
recent cases the hair follicles were either without hair, or 
contained a lanugo hair or a hair just about to fall. The 
hair-roots, where present, showed atrophic changes. In 
advanced cases' the sebaceous glands vrere degenerated or 
had entirely disappeared. In the worst cases there was 
complete atrophy of the hair follicles and of the subcuta- 
neous fatty tissue. He also describes the presence of various 
cocci in the lymph spaces of the corium and the walls of a 
few of the vessels, which he regards as the cause of the disease. 

Diagnosis. A typical case of alopecia areata is so pecu- 
liar that there is little danger of mistaking it for anything 
else. It differs from trichophytosis capitis in its sudden 
onset, its perfectly bare, smooth, non-scaly surface, without 
broken, split, and gnawed-off hairs, and in the absence of 
the trichophyton fungus from the hair and scales taken from 
the neighboring parts. In bald ringworm patches, which 
resemble alopecia areata, the fungus will be found in the 
neighboring hair, or some characteristic " stumps " will be 
found on the scalp. In adults, ringworm of the scalp is 
very rare. It differs from favus in the absence of cupped 
crusts at any time in its course, in the scalp not presenting 
that cicatricial appearance always met with in favic bald- 
ness, and in complete absence of fungus growth. 

The baldness due to syphilis may resemble that of alopecia 
aerata, but other symptoms of syphilis will be present, and 
there will never be a history of the formation of well-defined 
oval or circular areas. Lupus erythematosus at times affects 
the scalp, and produces circumscribed bald areas ; but these 
are not oval or round, and the skin is red and scaly, and 
evidently cicatrized. The alopecie innominee of Besnier 
is extremely difficult to diagnose from alopecia areata. It 
differs in not forming regular oval or round bald areas, but 
rather irregular ones, with clumps of hair at their borders ; 
in having a cicatricial appearance ; and in presenting, at 
first, at least, some evidences of dermatitis or folliculitis. 
This type of baldness has not yet become well recognized. 



84 DISEASES OF THE SKIN. 

Treatment. In a disease that is essentially self-limited 
it is hard to estimate how much good our remedies do. One 
duty we have without peradventure, and that is, to look after 
the general condition of the patient. A large number of the 
cases require a stimulating and tonic treatment — iron, quinine, 
strychnine, arsenic, cod-liver oil, or hypophosphites. Chil- 
dren should be allowed to run free and taken out of school. 
Our hardest task will be to manage those nervous patients 
who are ever a trouble to us. 

As far as local treatment is concerned, it may be summed 
up in two words : patience and stimulation. As many of 
our parasiticides are stimulating to the skin, they may be 
used with benefit, whether we believe in the parasitic cause 
of the disease or not. 

The stronger water of ammonia dabbled on to the scalp 
by means of a swab, care being taken to guard the eyes, will 
be beneficial in some cases. It is remarkable how little re- 
action this powerful remedy will cause in alopecia areata. 
Pilocarpine, in hypodermic injections, or in ointment form, 
is at times beneficial. Sulphur ointment well rubbed in ; 
painting the scalp with acetic acid until it whitens, and then 
sponging off with cold water, and repeating every three or 
four days ; chrysarobin, (fifteen or thirty grains to the ounce, 
well rubbed into the scalp once a day ; carbolic acid (95 per 
cent.) applied every two weeks or so to small areas at a time ; 
the bichloride of mercury, two to four grains to the ounce 
in alcohol, or oleum pini sylvestris ; the oleate of mercury, 
in the strength of 2 to 10 per cent. ; blistering with can- 
tharides ; or 33J per cent, of iodine in collodion, and gal- 
vanism, have one and all been followed by the return of 
the hair. 

Moty 1 reports good results from hypodermic injections of 
bichloride of mercury, injecting five or six drops of an 
aqueous solution (1 : 500) into many places about each 
patch. In a later number of the same journal (p. 864) he 
announced that he then used a 4 per cent, solution of the 
mercury, with a 2 per cent, solution of cocaine; that he 

1 Ann. Derm, et Syph., 1891, ii. 406. 



ANGIO-KERATOMA. 85 

made but a single-drop injection in a medium-sized patch, 
and four to five injections about a large patch and at its 
periphery. Pauses of four days were taken between the 
injections, and a cure is expected after the fourth series. 

It is advisable to pluck the loose hair from around the 
patch for a zone of perhaps an eighth or a quarter of an 
inch. Every few days slight traction is to be made on the 
hairs surrounding the patch, and all the loose ones pulled. 
Massage is also useful. 

Prognosis. Even if left to itself, the chances are that 
the hair will grow in again. This good prognosis should 
be guarded when the patient is past middle life, and in those 
malignant cases in which there is complete baldness that has 
lasted several years, 

Alopecia Circumscripta. See A. areata. 

Alopecie Innominee. See Folliculitis decalvans. 

Alphos. See Psoriasis. 

Anaesthesia (A 2 n-e 2 s-the / zi 2 -a 3 ) is a loss of sensation in 
the skin which occurs in a number of diseases of the nervous 
system, notably in hysterical affections. It may be general, 
or partial, or affect but one-half of the body. There may 
be loss of sensibility to pain while the tactile sense is pre- 
served {analgesia), or intense pain with loss of ordinary 
sensibility (anaesthesia dolorosa). There are many sub- 
stances which locally applied will cause anaesthesia, such as 
carbolic acid, cocaine, aconite ; and many others which will 
abolish sensation when taken internally. The subject be- 
longs to the domain of the neurologist. 

Anatomical Tubercle. See Tuberculosis verrucosa cutis. 

Angio-keratoma 1 (An 2 -gi-o-ker 2 -a 2 t-o'ma 3 ) is the name 
given by Pringle to a peculiar disease of the skin of the 
hands, feet, and ears, that has been called telangiectatic 
warts or verrues telangiectasiques. 

Symptoms. It follows chilblains, and affects principally 
the dorsal aspects of the hands and feet, though their plantar 
surface may be involved to a slight degree. The eruption 

1 Brit. Journ. Dermat., 1891, iii. 237. 
5 



86 



DISEASES OF THE SKIN. 



consists in tiny, almost imperceptible pink points, that do 
not disappear on pressure ; of pin-point to pinhead darker 
spots that can be made almost to disappear on pressure, 
leaving a deep-red capillary loop in the centre ; and of clus- 
tered telangiectatic points forming small irregularly shaped, 
slightly elevated groups. These groups may be as large as 



Fig. 10. 




Angiokeratoma. (Mibelli.) 



a split-pea or bean ; they may project for half a line above 
the surface ; are hard, rough, warty-looking, and of dull 
purplish-brown color. Pressure upon them brings out the 
telangiectatic character of the growths. When pricked with 
a needle free hemorrhage takes place. The eruption is 
symmetrical -as a rule, and usually affects more than one 



ANGIOSES. 87 

member of a family. It begins in childhood. There are 
no subjective symptoms. 

Tkeatment. The treatment that proved most beneficial 
was by electrolysis. 

Angeioma (A^-ji-o'ma 3 ) or Angioma. An angioma is a 
tumor or new growth made up of bloodvessels or lymphatics. 
It is usually congenital. For convenience the vascular 
angiomata will be described under Nsevus, and the others 
under Lymphangioma. 

Angioma Pigmentosum et Atrophicum is the name pro- 
posed by R. W. Taylor for the xeroderma of Kaposi, and is 
described in this book under Atrophoderma pigmentosum, 
which see. 

Angioma Serpiginosum. This is a rare disease of which 
but few cases have been reported. White 1 describes the 
disease as beginning as minute papules that slowly increase 
to the size of a pea and then undergo spontaneous involu- 
tion in the central portions, while they spread outward in an 
annular form to an indefinite extent and for an indefinite 
period. By the end of ten years the circinate patches may 
be no larger than one or two inches in diameter. The 
margin of the rings is elevated and of uniform breadth. 
New foci continually develop at a distance of one-eighth to 
one-third of an inch beyond the older areas. These, in turn, 
are converted into rings in the same way. The lesions are 
firm and smooth and are of bright-red to claret color. The 
centre of the rings is not elevated, but remains of a dull 
pinkish-brown tint. There are no subjective symptoms. 
White's case was on the right shoulder. Other cases have 
been on the arm, cheeks, and leg. 

Most of the cases develop in early life. The pathology 
is undetermined. In White's case the growths were com- 
posed mostly of endothelial cells and the disease was thought 
to be of sarcomatous nature. Electrolysis is the only treat- 
ment suggested. 

Angioses. " Disorders of the cutaneous vascular appa- 

1 Journ. Cutan. and Gen.-urin. Dis., 1894, xii. 505. 



88 DISEASES OF THE SKIN. 

ratus which embrace the common effects of engorgement, 
ischsemia, transudation, and inflammation." 1 

Anhidrosis (A 2 n-hi 2 d-ro'-si 2 s) or Anidrosis (A 2 n-i 2 d-ro / si 2 s). 
By this is meant an affection of the sweat glandular appa- 
ratus attended by a diminution, or more or less complete 
suspension of its functions. It is a symptom rather than 
a disease. It may be local or general ; temporary or per- 
manent; symptomatic, as in fevers and diabetes; congenital, 
as in xeroderma ; or neurotic. Some people never sweat 
perceptibly. In certain skin diseases, such as psoriasis, 
scleroderma, squamous eczema, and ichthyosis, the affected 
areas do not sweat. Its treatment is tonic by exercise and 
bathing. In symptomatic cases we must strive to remove 
the underlying cause. For congenital cases we can do 
nothing. 

Anonychia (A 2 n-o 2 n- i 2 k'-i 2 -a 3 ) means congenital absence 
of the nail. 

Anthrax (A 2 n-thra 2 x). See Carbuncle and Pustula 
maligna. 

Aplasie Moniliforme. See Trichorrhexis nodosa. 

Area Celsi. See Alopecia areata. 

Argyria (A 3 r-j 2 ir-i 2/ a 3 ) is the blue or black discoloration of 
the skin and mucous membranes, due to the deposition of 
particles of silver in the rete, sweat glands, and about the 
hair follicles, where it turns black by exposure to the sun- 
light. It used to be seen more often than now, when silver 
salts were administered in the treatment of epilepsy. It is 
also seen in workers in metallic silver, minute particles of 
the metal becoming fixed in the tissues. It is a permanent 
staining. 

Arthritide Pseudo-exanthematique. See Pityriasis rosea. 

Asteatosis (A 2 s-te-a 3 -to'-si 2 s), an absence of sebaceous 
matter. See Xeroderma. 

Atheroma (A^h-eVo'-ma 3 ). See Sebaceous Cyst. 

Atrichia. See Alopecia adnata. 

1 Bronson : Journ. Cutan. and Gen.-urin Dis., 1887, v. 371. 



ATROPHIA PILORUM PROPRIA. 89 

Atrophia Pilorum Propria. Atrophy of the hair exists 
under two forms, namely, Fragilitas crinium, and Trichor- 
rhexis nodosa. In both forms the hair shaft is easily fria- 
ble and splits or breaks of itself, or by the slightest traction. 

Fragilitas Crinium. This disease has been called scis- 
sura pilorum, and has for its distinguishing features split- 
ting of the hair. The cleft is usually at the free extremity, 
and at times runs some distance up the shaft. The split 
hairs are either scattered here and there through the other- 
wise normal hair, or all the hairs of the part are split. 
The disease occurs most often upon the scalp, the beard 
being the place next most frequently affected. It is a com- 
mon occurrence in the long hair of women. The shaft may 
be split into two or more fibrillse, and these spread out from 
each other simply, or curve up upon themselves. The 
cleft may also occur in the middle of the shaft, or at its 
exit from the follicle, and in the latter case the shaft will be 
split throughout its entire length, the segments either sepa- 
rating or holding together. Duhring 1 has reported a case 
occurring in the beard in which the hair began to split 
within the bulb. Besides the splitting, the hair may show 
no other abnormality, but it is generally more dry and 
brittle than normal, and may be irregular and uneven in 
its contour. The bulb of the hair may be normal or atro- 
phied. 

Etiology. The cause of the idiopathic fragilitas crinium 
is yet undetermined. The disease is, without doubt, due to 
some interference with the nutrition of the hair, probably 
a yet undetermined tropho-neurosis. 

Tkeatment. When occurring only at the free end of 
long hairs, they should be cut above the cleft. In all cases 
the scalp should be kept in good condition, as directed under 
Alopecia prematura. If the disease occur in the beard, 
shaving would at least remove the deformity, and possibly 
cure the disease. 

Trichorrhexis Nodosa. Synonyms : Trichoclasia ; Tri- 
choptylose ; Clastothrix. 

1 Amer. Jour. Med. Sci., July, 1878, p. 88. 



90 



DISEASES OF THE SKIN. 



Symptoms. The disease most often affects the hair of 
the beard and moustache, and here it reaches its highest 
development. It is found also in the hairs of the pubic 
region, and still more rarely in the scalp-hair. Raymond 1 



Fig. ll. 



Trichorrhexis nodosa. (Michelson.) 

says that he has found it on the labia majora in 40 per 
cent, of all women he has examined, and specially in fat 
women with intertrigo. He has found it also on scrotal 
hairs. It consists of one or more whitish or grayish 
shiny transparent nodular swellings occurring along the 

1 Ann. Derm, et Syph., 1891, ii.p. 568. 



ATROPHIA PILOBUM PROPRIA. 91 

shaft of the hair. In people with red hair the color may 
be black. The number of nodes that may be present is 
from one to five ; and their size will vary with the diameter 
of the hair. The nodes, according to S. Kohn, 1 occur 
usually in the upper third of the hair. These nodes give 
to the hair an appearance not unlike that produced by the 
presence of the nits of pediculi. The hair is exceedingly 
brittle and fractures upon slight traction, or spontaneously, 
the fracture taking place through a node and the hair fibres 
separating like the hairs of a brush. When many hairs in 
the beard are thus broken, their frayed-out ends make the 
beard look as if it were singed. Sometimes the hair fibres 
splinter about the node, but the two ends do not separate, 
and this gives an appearance like as if two small paint- 
brushes were pushed together. Sometimes the hair pre- 
sents an irregular contour, and looks as if frayed along its 
entire length. While the fracture is usually transverse, if 
there should be an excessive amount of medulla present in 
the node, it may be longitudinal. The hairs themselves are 
usually firmly fixed in the follicles. 

Etiology. The cause of the disease is probably a para- 
site. Micro-organisms have been found in relation to the 
disease by Hodara, Essen, and others. Anderson 2 has re- 
ported a case of hereditary trichorrhexis nodosa, the disease 
in his patient being congenital or nearly so. 

The cause of the splitting of the hair is ascribed by some 
investigators to a degeneration of the medulla, a conse- 
quent rapid accumulation of cells at one point which event- 
ually bursts open the hair sheath. Pye-Smith 3 regards it as 
due to a gradual drying of the cortical substance, and a 
consequent loss of coherence of its constituent fibre-cells, 
followed by the breaking up into a granular material and 
swelling of the cells of the medulla, till the rupture of the 
cortex is complete, there being nothing left to hold the hair 
together. 

1 Vierteljahr. f. Derm. u. Svph., 1881, viii. 581. 

2 Lancet, 1883, ii. 140. 

3 Trans. Path. Soc, Lond., 1879, xxx. 439. 



92 DISEASES OF THE SKIN. 

By some it is regarded as purely mechanical, due to the 
habit of the patient of handling the beard. 

The microscopical examination of the affected hairs shows 
that in the early stage of development of the disease there 
is simply a spindle-formed thickening in the continuity of 
the shaft of the hair and a swelling of the medulla, while 
the cuticle is still intact. Later the cuticle becomes cleft, 
and the cleavage extends on all sides of the node till the 
brush-like appearance is produced by spreading of the sepa- 
rate fibres. At the same time with the cleaving of the cuti- 
cle, the medulla undergoes degenerative changes, and either 
slowly disappears or else, according to Pye- Smith, oozes out 
between the separated fibres as a finely granular material. 
There is either no marked change in the appearance of the 
hair-root, or it is slightly atrophied. Air-globules are only 
very occasionally found in or about the nodes. 

Treatment. The treatment of the disease is very un- 
satisfactory. Continued shaving probably offers the best 
hopes of any plan. All sorts of applications have been 
made to the affected parts, generally of a stimulating char- 
acter, particularly various forms of mercurials, but without 
curative effect. Gamberini, in his work on the hair, rec- 
ommends either bathing the part with a lotion composed as 
follows : 



R. Potass, subcarb., 3 iij ; 8 

Alcohol, dil., Sfv; 100 

or inunctions of tannic acii or oil of cade. 
Schwimmer advises that an ointment of 

R . Zinci oxid , gr. vij ; 1 

Sulphur, loti, gr. xv; 3 

Ung. simp. , 3 iiss ; 30 



M. 



M. 



be rubbed in the morning and evening. 

Besnier finds it useful to pluck the diseased hairs and to 
apply to the newly formed hairs tincture of cantharides, pure 
or diluted. A two per cent, solution or ointment of pyro- 
gallol, or a three per cent, carbolic acid ointment has been 
advised by others. 



ATROPHODERMA. 



93 



Atrophia Unguium. Atrophy of the nails occurs as a 
symptom of very many diseases of the skin, such as lichen 
ruber acuminatus, pityriasis rubra, psoriasis, and syphilis ; 
or it may be caused by the invasion of the nail-bed by para- 
sites, as in favus and ringworm. It may also occur like 
defluvium capillorum as a sequence to some grave acute 
illness such as typhus fever or scarlatina, or some cachexia, 
such as diabetes. The nails may be congenitally absent or 
deficient, or become so without apparent cause. Injuries, 
and certain chemicals, will cause the nails to atrophy and 
fall. Atrophy is shown by white spots in the nails, by loss 
of lustre, by transverse white lines, by longitudinal or trans- 
verse furrows, by a worm-eaten appearance, or by a general 
thinning and breaking away of the nail-plate. 

Treatment. The treatment is most unsatisfactory. If 
the cause can be discovered and removed, the nails will re- 
cover. In many cases all we can do is to protect the nail 
by rubber cots, or by the use of wax or other protective. 
Ointments of lead, zinc, or mercury may be rubbed in. 
The persistent use of sulphur ointment, combined with the 
administration of nerve tonics, will prove beneficial in those 
cases apparently dependent upon nerve-disturbance. 

Atrophoderma or Atrophia Cutis. Atrophy of the skin 
may be quantitative or qualitative ; idiopathic or sympto- 
matic ; diffused or circumscribed. Crocker 1 gives this use- 
ful table : 



f 



Atrophoderma 
Idiopathicum. 



; 



Diffusum 



Juvenilis 
Senilis 



{ 



| Circumscriptum 

[ (strise et maculae) 

Neuriticum 

(glossy skin) 



Atrophoderma 
Symptomatictjm ' 



Morborum cutis 



Pigmentosum. 
Albidum 
Quantitation in. 
Qualitativum. 
Traumaticum. 
Non- tr aum aticum . 

f Traumaticum. 
\ Non- traumaticum. 
f Scleroderma, 
j Seborrhoea. 
\ Lupus. 
I Syphilis. 
[ Favus, etc. 



1 Diseases of the Skin, Lond. and Phila., 1888. 
■ 5* 



94 



DISEASES OF THE SKIN. 



The symptomatic atrophies due to other diseases will be 
spoken of under their proper headings. The other forms 
of atrophy will be considered here. 

Atrophoderma Pigmentosum. Synonyms : Xeroderma 
pigmentosum (Kaposi) ; Angioma pigmentosum et atro- 
phicum (Taylor) ; Dermatosis Kaposi (Vidal) ; Liodermia 



Fig. 12. 





illiiilllM 



Atrophoderma pigmentosum. (After Crocker.) 

essentialis cum melanosi et telangiectasia (Neisser) ; Mel- 
anosis lenticularis progressiva (Pick) ; Lentigo maligna 
(Piffard) ; Epitheliomatose pigmentaire (Besnier). This is 
a very rare disease of the skin, first described by Kaposi in 
1870 under the name of xeroderma, to which he subse- 
quently added the adjective pigmentosum. Only some fifty- 
six cases have been reported. It is a congenital disease ; 
almost all cases begin before the second year of life. 



ATROPHODERMA. 95 

Symptoms. It affects the parts most exposed to the air ; 
the face, neck, chest, and back down to the level of the 
clavicles, or even the third rib, the backs of the hands, fore- 
arms and upper arms. The hands, face, and neck are most 
markedly diseased, while a few cases have occurred upon 
the legs and backs of the feet. It begins with erythematous 
patches, like those produced by sunburn. After a time 
brown or black freckle-like spots form upon the erythema- 
tous ones. They are from pin-head to bean size, and round 
or irregularly shaped. Small red spots appear among the 
pigmented lesions, which Taylor thinks are their fore- 
runners. The pigmented spots in time give place to white 
atrophic ones, and the skin becomes too small for the un- 
derlying parts, so that it appears drawn, and in some places 
bound down. A fully developed case presents a vast num- 
ber of lentiginous spots, interspersed with white atrophic 
spots and stellate and striated telangiectases. After a time, 
on account of the atrophy of the skin, we find ectropium, 
thinned alse nasi, and contracted nasal and oral orifices. 
There may be white atrophic spots on the mucous mem- 
brane of the lips. Conjunctivitis generally supervenes 
upon the ectropium and discharge from the eyes sets up 
ulcerations which in their turn give rise to other ulcerations. 
Warty growths at last appear, and these are prone to take 
on malignant action and be converted into epitheliomas, and 
the patient dies at an early age from marasmus. At first, 
however, there is no disturbance of the health. 

Etiology. The etiology of the disease is obscure. It 
is supposed by some to have its starting-point in irritation 
of the skin by the sun or other irritant. Many of the cases 
begin in the summer. It is supposed by others to be a 
tropho-neurosis. It is found in both sexes about equally, 
but is peculiar in affecting several members of the same 
family and of the same sex, and in occurring in early child- 
hood in most of the cases. It is not hereditary. In a few 
of the cases there was a history of cancer. 

Diagnosis. The disease is to be differentiated from sclero- 
derma by the peculiarity of its being limited to exposed 
parts, by lacking stony hardness, by occurring early in life, 



96 DISEASES OF THE SKIN. 

and by the general picture of pigmented and atrophic spots 
and telangiectases being intermingled. It differs from urti- 
caria pigmentosa in not itching and in not occurring upon 
the trunk, and in having telangiectases and warty or epithe- 
liomatous growths. 

Treatment. Nothing has yet been found to stop the 
progress of the disease. The conjunctivitis is to be cared 
for, the ulcerations on the face healed as rapidly as possible, 
and the warty growths and epitheliomatous nodules de- 
stroyed at an early date so as to prevent the development 
of epitheliomatous or carcinomatous ulcers. A saturated 
solution of boric acid will do much for the eyes ; the ulcers 
may be treated with iodoform or aristol powder, or a dilute 
ammoniate of mercury ointment ; while the warty growths 
should be scraped off with the sharp spoon. 

Atrophoderma Albidum is the name used by Crocker for 
a second form of the xeroderma pigmentosum of Kaposi, 
which is described by the latter as beginning in childhood ; 
affecting most frequently the lower extremities, and less 
often the forearms and hands ; and characterized by thinness 
of the skin, which in some places is stretched and cannot be 
readily taken up into folds. The color of the skin is pale 
and white with a delicate rosy shimmer in places ; and here 
and there its epidermis peels off in asbestos-like lamellae. 
The treatment is simply protective. 

Atrophoderma Idiopathica Diffusa. Diffused idiopathic 
atrophy of the skin is a very rare affection. It may be con- 
genital or acquired, general or partial. The subcutaneous 
tissue disappears, so that the skin lies close to the under- 
lying parts. It is thin, pale, stretched, easily movable 
over underlying parts, and allows the bloodvessels to show 
through. In some cases thick scaly plates form, while in 
others these are wanting, and there is only slight scaling. 
The elasticity of the skin is lost, so that if it is pinched up 
into folds these slowly flatten out. In some cases the skin 
seems too small for the body, which, on the face, gives rise 
to ectropion and other deformities. The sensibility of the 
skin may not be diminished. The patients are susceptible 



ATROPHODERMA. 97 

to cold. Ulcers are prone to form upon slight injuries. 
The hair is destroyed. The disease is probably a tropho- 
neurosis. One case was ascribed to exposure to cold. 1 

Hardaway 2 reported two cases occurring in a brother and 
sister; and Ohmann-Dumesnil 3 has met with a case of 
atrophy of the skin and muscles of the right arm apparently 
following an injury to the radial nerve by means of a burn 
on the hand. 

One variety of diffused idiopathic atrophy of the skin is 
that called hemiatrophia facialis progressiva, in which only 
one-half of the face is affected, and the skin becomes thinned 
and shrunken so that it lies close to the bones. 

Under this heading may also be placed the glossy shin of 
Paget, Weir Mitchell, and others. It commonly affects the 
fingers, less often the extremities, and follows upon disease 
or injury of nerves. The fingers become dry, red, or mot- 
tled, look glazed or as if varnished, and are shrunken. The 
natural lines of the skin disappear, and the nails fall off. If 
parts covered with hair are affected, the hair falls. The 
tendency is to spontaneous recovery. 

Atrophoderma Senilis is a true atrophy of the skin that 
takes place in consequence of advancing years. Other 
degenerative changes are also present, as a rule. It may 
be partial or general. The skin looks wrinkled ; it is thrown 
into folds ; is dry and sometimes scaly, and is often of darker 
color than normal. By pinching up the skin the thinness 
of it is readily appreciated. With the atrophy of the skin 
there are likewise loss of the subcutaneous fat, pruritus, and 
verruca senilis. Treatment is out of the question. 

Atrophoderma Striatum et Maculatum. By this is meant 
circumscribed atrophic streaks or spots. They may be 
idiopathic or symptomatic. The idiopathic form is far more 
rare than the symptomatic form. 

Symptoms. The idiopathic streaks are met with most 
often about the thighs, buttocks, and lower anterior part of 

1 Pospelow : Ann. Derm, et Syph., 1886, vii. 505. 

2 Trans. Amer. Derm. Association, 1884. 

3 Alienist and Neurologist, July, 1890. 



98 DISEASES OF THE SKIN. 

the abdomen. They are one or two lines wide, slightly 
curved, and from one to several inches long. There are 
usually several present, and then they are arranged parallel 
to one another and run in an oblique direction. The 
macules are isolated, from pin-head to finger-nail size or 
larger, occur most frequently on the lower part of the 
trunk, but may occur as high up as the neck, and are less 
common than the streaks. Both forms of lesion are de- 
pressed below the surface of the skin, and of a pearly or 
bluish-white color, and have a glistening, scar-like appear- 
ance. They are not primary atrophies, but succeed to an 
erythematous hypertrophic lesion, in this greatly resem- 
bling morphcea. They give rise to no inconvenience, and 
are accidentally discovered. They usually are permanent, 
though they may become less pronounced in time. 

Etiology. Their etiology is obscure. By many they 
are regarded as tropho-neuroses. Shephard 1 and Duck- 
worth 2 have reported cases of atrophic spots and lines fol- 
lowing fevers. 

Symptomatic lines and macules are very common, and 
are caused by the stretching or rupture of the more super- 
ficial bundles of white and elastic fibrous tissue of the skin. 
If the fibres are ruptured, the striae will be most pronounced, 
and there will be little left of the skin but the epidermis 
and a thin fibrous membrane. 3 This form of atrophy of the 
skin is seen upon the abdomen of pregnant women (linea? 
albicantes), and on the breasts of nursing women. In fact, 
anything that greatly distends the skin may give rise to 
them, such as abdominal ascites, ovarian or other tumors. 

Treatment. The treatment of these cases is purely ex- 
pectant. Both the idiopathic and symptomatic atrophies 
may grow less pronounced in time. 

Aussatz. See Leprosy. 

Autographism. See Urticaria factitia. 

Arzneiexantheme. See Dermatitis medicamentosa. 



1 Trans. Amer. Dermat. Assn., 1890, p. 23. 

2 Brit. Journ. Dermat., 1893, v. p. 357. 

3 Taylor, R. W. : N. Y. Med. Journ., 1886, xliii. p. 1. 



BROMIDROSIS. 99 

Baelzer's Disease of the lip is a chronic affection of the 
mucous glands of the lip marked by an indolent swelling 
and infiltration of the periglandular tissue, and a slow 
ulceration from above downward. It ceases only with the 
destruction of the affected gland. The neighboring lym- 
phatic glands are not implicated. A superficial catarrhal 
inflammation of the mucous membrane of the lips frequently 
accompanies the process. There is no general systemic 
disturbance. It has no relation either to syphilis, tuber- 
culosis, or cancer. It is regarded as a local infection. It 
is readily cured by the application of tincture of iodine, 
which at first is used every other day, and later every day. 

Baker's Itch. See Eczema. 

Baldness. See Alopecia. 

Barbadoes Leg. See Elephantiasis. 

Barber's Itch. See Trichophytosis barbae. 

Bartfinne or Bartflechte. See Sycosis. 

Birth-mark. See Nsevus. 

Biskra Bouton or Biskrabeule. See Aleppo boil, 

Blackheads. See Comedo. 

Blasenausschlag. See Pemphigus. 

Blutfleckenkrankheit. See Purpura. 

Blutgeschwiir or Blutschwar. See Furunculus. 

Blutschweiss. See Haamatidrosis. 

Boil. See Furunculus. 

Bouton. See Acne. 

Bouton d'Amboine. See Yaws. 

Brandrose is a phlegmonous erysipelas. 

Brandschwar. See Carbuncle. 

Bricklayer's Itch. See Eczema. 

Bromidrosis (Brom-i 2 d-ro'si 2 s). Synonym : Osmidrosis. 
This word means stinking sweat, which, though not elegant, 
is expressive. It most often affects the feet, and then is 
associated with hyperidrosis. It may be general, as in the 
negro race. The odor is not necessarily repulsive, a few 



100 DISEASES OF THE SKIN. 

cases having been reported in which it was that of violets. 
The axillae are, next to the feet, the most common site of 
the trouble. The odors of different fevers and cachexise 
are usually classed under this heading, though they do not 
properly belong here. 

Strictly speaking, bromidrosis should include those rare 
cases alone in which the sweat, when secreted, has a dis- 
tinctive odor. Usually the odor in bromidrosis is not in 
the sweat, but in the products of decomposition, the fatty 
acids, and the like. When the feet are the parts affected 
they will be found to be of a pinkish color about the soles 
and between the toes, or the skin will look sodden and 
grayish. When the hyperidrosis is well marked, and it 
commonly is, the feet may be so tender as to interfere with 
locomotion. The stench from a pronounced case is such 
that it is almost impossible to stay near the subject of the 
disease. 

Etiology. The cause of general bromidrosis is either 
inherent in the race, or unknown. Most of the cases, apart 
from the racial ones, have been in hysterics. In the usual 
form of the disease it is due to decomposition of the sweat 
in the stockings, shoes, or clothing of the individual. When 
the part is uncovered and kept clean there is no odor. Thin 
has described a parasite, that he has named bacterium 
fcetidum, as the cause of the disease. It has been supposed 
that this bacterium can live only in an alkaline medium. 
The sweat is acid, and therefore on most feet it does no 
harm ; but when hyperidrosis macerates the epidermis and 
allows of the escape of serum, the acidity of the sweat is 
neutralized, and the bacterium flourishes. 

Treatment. The treatment of the general cases is of no 
effect. In the local cases the hyperidrosis is to be over- 
come, as will be described in its proper place. The special 
treatment directed to the cure of the odor of the feet is to 
wash them with soap and water two or three times a day, 
to put on a clean pair of stockings every morning, to venti- 
late the shoes thoroughly, and to dust the feet, between the 
toes, the stockings, and the inside of the shoes with boric 
acid. Thin recommends the wearing of cork inside soles, 



CANCROIDE. 101 

which are to be soaked in a saturated solution of boric acid 
and dried before using. Another useful powder is : 

R . Ac. salicylici, g jss-iij ; 5-10 

Pulv. alum exsic vel. \ 5i" • 100 

Pulv. lycopodii, J 5 J > M # 

to be applied in the same way, twice a day. This will 
cause the skin to exfoliate, when the treatment may be 
stopped. 

Bucnemia Tropica. See Elephantiasis. 
Cacotrophia Folliculorum. See Keratosis pilaris. 
Calculi, Cutaneous. See Milium. 

Callositas (Ka 2 l-loVi 2 t-a 2 s). Synonyms : Callosity ; Cal- 
lus ; Tylosis ; Tyloma ; (Fr.) Durillon. This is familiar to 
all as the callous skin of the hands met with in oarsmen, 
blacksmiths, and in those who follow other manual occupa- 
tions, and is a hypertrophy of the epidermis consequent upon 
intermitent pressure of the skin against the underlying 
bone. Constant pressure will cause atrophy. The same 
thickenings of the skin are found upon the soles also, due to 
going barefoot or wearing improperly fitting shoes. In fact, 
they may develop anywhere under proper conditions. 

Treatment. No treatment is necessary for the acquired 
forms. Cessation from using the hands will be followed in 
course of time by the disappearance of the callus. To hasten 
its removal we may use maceration with rubber cloth 
continuously applied to the part, or a plaster of salicylic 
acid, or a solution of salicylic acid ten to twenty per cent, in 
ether or collodion. The action of these remedies will be 
aided by previously paring down the part with a sharp 
knife. 

Callus. See Callositas. 

Calvez "\ 

Calvezza V See Alopecia. 

Calvities J (Ka 2 l-vi 2 -s'h'i 2 ez). 

Cancer. See Carcinoma and Epithelioma. 

Cancroide. See Epithelioma. 



102 DISEASES OF THE SKIN. 

Canities (Ka 2 n-i 2/ shi 2 -ez). Synonyms: Trichonosis cana; 
Trichonosis discolor ; Poliothrix ; Poliosis ; Trichonosis 
poliosis ; Trichosis poliosis ; Spilosis poliosis ; Poliotes ; 
Grayness of the hair ; Whiteness of the hair ; Blanching 
of the hair; Atrophy of the hair pigment. 

Grayness or whiteness of the hair may be congenital or 
acquired ; the latter is by far the most common. The 
whiteness is either partial or complete. 

Congenital canities usually occurs in the form of tufts, 
sometimes in round patches, the more or less pure white 
hair showing conspicuously amongst the normal-colored 
mass. When the whiteness is general, we have albinism 
which is associated with a deficiency of pigment in the 
whole body. Cases of congenital canities are rare. 

Acquired canities may be premature or senile. Most 
often grayness does not begin before the thirty-fifth or 
fortieth year. If it occurs before this age, it may be con- 
sidered as premature ; and when after this age, as senile. 
Premature canities is by no means uncommon, many per- 
sons becoming gray between the twentieth and twenty-fifth 
year. The hair which, as a rule, first whitens is that of 
the temples ; then follows, with more or less rapidity, that 
of the vertex and whole head. Sometimes the beard first 
turns gray, but usually it changes color after the hair of 
the scalp. The last hair to become gray is that of the 
axillae and pubis. When the graying is due to some pass- 
ing cause, as anxiety or some diseased state, the process 
may cease completely upon removal of the cause. Usually 
the whiteness is permanent. As a rule, there is no change 
in the color of the scalp, though in some cases gray tufts 
are found upon pale-yellow patches of scalp. As in alopecia, 
so in canities, men are more frequently affected than 
women. 

The hair in canities is usually unchanged except in color, 
but it may be drier and stiffer than normal. Canities may 
exist for years without alopecia. According to Landois, 
incipient baldness usually follows senile canities in from 
one to five years. 

The hair turns gray first at its root. The color at first 



CANITIES. 103 

is gray on account of the mixture of the normal color with 
the whiteness due to the absence of pigment. Gradually, 
the white parts gain the ascendant, and the whole hair is 
blanched, becoming finally of a yellowish or snowy white- 
ness. The darker the hair is originally the more it is prone 
to turn gray. 

Sudden change of color of the hair from its normal hue 
to perfect white has been too well authenticated to allow of 
a doubt as to its occurrence, though it has been denied by 
good authorities, who have questioned the correctness of 
the observations reported. 

Ringed hair is an anomalous variety of blanching of the 
hair in which the affected hairs are marked by alternate 
rings, one being that of the normal color, and the next white. 
The occurrence of this disease is very rare, and but few 
cases have been reported. 

The hair has been known to lose its color under varying 
circumstances. Thus Wallenberg 1 reports a case in which, 
after an attack of scarlatina, the patient's brown hair was 
entirely lost, and replaced by a growth of white hair. Pro- 
longed residence in a cold climate, with much exposure, will 
cause the hair to turn gray. Sometimes the hair will 
change its color with the season, becoming gray in winter 
and darker in summer. On the other hand, Cottle 2 gives 
prolonged residence in hot climates, with much exposure, as 
a cause of canities. Albinoes, we know, are most frequent 
in the negro races, which inhabit the hot countries. 

Etiology and Pathology. Senile canities and many 
cases of the premature form are due to an obscure change 
in the nutrition of the hair papillae which interferes with 
the production of pigment. Whatever the nature of the 
change may be, only this function of the papillae seems to 
be interfered with, as the hair-forming function is in full 
activity, judging from the fact that the hair in many cases is 
in full vigor. In cases of sudden blanching of the hair the 
change of color is dependent upon the formation of air- 

1 Vrtljhrschrft f. Derm, und Syph., 1876, III., 63. 

2 The Hair in Health and Disease. London, 1877. 



104 DISEASES OF THE SKIN. 

bubbles between the hair cells of the cortical substance, the 
presence of the air rendering the cortical substance opaque, 
so that the color of the pigment is obscured. If one of 
these hairs is placed in hot water, ether, or turpentine, the 
air-bubbles will be driven out, and the hair will reassume 
its normal color. There are various agents which act as 
active or exciting causes of canities. Age is one of the most 
prominent of these. Heredity exerts marked influence upon 
the blanching of the hair, most of the members of certain 
families turning gray at an early period of life. Neuralgia 
of the fifth nerve, dyspepsia of various forms, sudden fear 
or nervous shock (producing sudden blanching of the hair), 
abundant and frequent hemorrhage, excesses of all kinds, 
chronic debilitating diseases (as syphilis, malaria, and 
phthisis), local diseases or injuries to the scalp, as wounds, 
favus, repeated epilation, prolonged shaving, and the like, 
have been given by various writers as causes of canities. 
Schwimmer regards it as being principally a tropho-neuro- 
sis, and finds in the occurrence of grayness in the course 
of neuralgia a strong argument for his theory. 

Treatment. We cannot restore the color to gray hairs. 
In some cases of canities occurring in the course of neural- 
gias, if we can cure the neuralgia, the color will gradually 
return to the hair. 

Besnier and Doyon suggest the use of acetic acid as a 
promoter of pigmentation, as they have seen numerous cases 
of its use in Alopecia areata being followed by the growth 
of hyperpigmented hair. 

All that can be done for canities is to restore artificially 
the color by means of hair dyes ; and their use is to be 
deprecated. Happily the custom of dyeing the hair is fall- 
ing out of fashion. 

Carbuncle (Ka 3 rb'-u 3 n-kl). Synonyms : Anthrax * Car- 
bunculus ; (Ger.) Brandschwar. 

A phlegmonous inflammation of the skin and subcuta- 
neous tissue, attended with sloughing. 

1 Anthrax, a term that is often applied to carbuncle, should be used 
rather for malignant pustule, or the local manifestation of splenic fever. 



CARBUNCLE. 105 

Symptoms. The disease begins as an innocent-looking 
papule, which, however, is far more painful, both subjec- 
tively and objectively, than an ordinary papule would be. 
Within twenty-four hours it becomes larger, more painful, 
slightly raised, and reddened, and is generally accompanied 
by a good deal of constitutional disturbance, such as chilis, 
fever, and nervous irritation. All the symptoms increase 
in severity, the inflammation extends laterally and verti- 
cally, the swelling becomes darker in color, the pain more 
intense, throbbing, and lancinating, and the constitutional 
disturbance may be so severe that the patient is compelled 
to go to bed. Within ten days, or perhaps longer, the 
swelling has reached its height. It may be two or three 
inches wide, with a brawny base that is more or less sharply 
defined, of irregular shape, firm to the touch, and with a 
wide area of cedematous skin about it. Now it begins to 
soften, not like a boil with a central point, but by the form- 
ation of a number of pea-sized purulent points, through 
which sanious pus exudes, giving to the surface a cribriform 
appearance. Sloughing takes place through the openings, 
that gradually enlarge, so that at last there results an irreg- 
ular, deep, excavated ulcer with firm, sharply cut, everted 
edges. In very bad cases the whole mass may fall out at 
once. The ulcer gradually fills up, heals, and leaves a scar. 
With the discharge of the slough the patient gradually re- 
covers his health, but in some cases, especially in already 
debilitated or in elderly people, the disease runs a fatal 
course, and they die of exhaustion or pyaemia, or the disease 
runs into a typhoid condition preceding death. Death may 
also result from acute sepsis, or from thrombosis or embolus, 
especially in carbuncles on the scalp. In some cases the 
resulting ulceration is very large, with a corresponding 
amount of general disturbance of the system. Dry gan- 
grene may take place. 

The disease is rare in children, and most common in mid- 
dle and old age. Men suffer more often than women. The 
location of the disease is most often the upper dorsal region, 
back, buttocks, and forearms, though it may occur any- 



106 DISEASES OF THE SKIN. 

where. It is usually a single lesion. The duration of the 
whole process is six weeks or more. 

Etiology. The causes of the disease are very much the 
same as those of boils. While carbuncle is most apt to 
occur in those who are not in good health, it does occur at 
times in apparently robust subjects. Diabetics are frequent 
subjects; gout and uraemia have been considered as predis- 
posing causes. The frequent location of the disease about 
the shoulders and on the back of the neck suggests pressure 
as a determining cause. Micro-organisms are the exciting 
cause of the disease, the staphylococccus pyogenes aureus 
being constantly found in the tissues of a carbuncle. 

Pathology. To Warren/ of Boston, we owe one of the 
most thorough studies of the pathology of carbuncle. He 
declares it to be a spreading phlegmonous inflammation of 
the subcutaneous cellular tissue. The inflammatory cells 
cluster in and about the columnse adiposse, and push out 
laterally from them, infiltrating the skin. They reach the 
surface by mounting up along hair follicles and erector pili 
muscles. 

Diagnosis. Carbuncle differs from furuncle in being 
single ; in its brawny base ; in its greater painfulness and 
constitutional disturbance ; in its flatter shape and larger 
size ; and especially in its opening at many points and pre- 
senting a cribriform surface rather than a central core and 
a crater-shaped opening. Its circumscribed shape, its lan- 
cinating pain, and its multiple sieve-like openings distin- 
guish it from diffuse phlegmonous inflammation of the skin. 
Anthrax becomes gangrenous earlier than carbuncle, and its 
centre sinks in instead of being elevated. 

Treatment. As the disease is an exhausting one, the 
patient's strength is to be supported from the start, and his 
nutrition kept up by a generous diet. Fresh air by good 
ventilation must be secured. If the pain is excessive, opium 
or morphine is indicated, especially to procure sleep. Iron 
is a valuable remedy all the way through, and antipyretics 
should be administered if the fever is marked. Alcohol 

1 Boston Med. and Surg. Journ., 1881, civ. 5. 



CARCINOMA. 107 

should be given if suppuration is free, especially if there are 
any signs of exhaustion. 

The best local treatment in mild cases is the use of car- 
bolic acid, and this gives such good results as to leave lit- 
tle to be desired. The crucial incision formerly practised 
is now considered by most modern authorities as harmful, 
though it certainly gives relief for the time by removing 
tension. In like manner the old-time method of poulticing 
is condemned, though it too contributes to the comfort of 
the sufferer. For ordinary carbuncles the most efficient 
treatment is to inject them at several points with a five or ten 
per cent, solution of carbolic acid in olive oil or glycerin, by 
means of an ordinary hypodermatic syringe. When there 
are already sloughing points it is well to push into each of 
them a little cotton wound on the end of a wooden toothpick 
and dipped in carbolic acid either pure or in one to four solu- 
tion. The procedures are painful for a moment. The mass 
must then be covered with lint soaked in a weak solution of 
carbolic acid. It is possible to abort some cases by touching 
them with pure carbolic acid. Eade, 1 to whom we owe this 
plan of treatment with carbolic acid, says that it is possible 
to abort cases in the papular stage by continuous soaking 
with a solution of a mild antiseptic, such as boric 01 sali- 
cylic acid. 

Canquoin's paste and a solution of chloride of zinc, 1 to 
50, have been recommended for use in the same way as the 
carbolic acid. 

Extensive carbuncles are to be treated on surgical princi- 
ples, by incision or erosion with the curette. The resulting 
raw surface, as well as that of ordinary carbuncles, is to be 
dressed antiseptically with iodoform, iodol, or aristol in 
powder. 

Carcinoma (Ka 3 r-si 2 n-o r ma 3 ). Epithelioma is the form of 
cancer that most frequently is met with in the skin. It will 
be described under its proper heading. Carcinoma of the 
scirrhous variety rarely attacks the skin, but when it does it 
may be primary or secondary. Most commonly it is 

1 Lancet, May 19, 1888. 



108 DISEASES OF THE SKIN. 

secondary to the same disease of the breast or internal 
organs. It may follow extirpation of the primary deposit, 
and then is prone to begin in the scar. Two varieties are 
described, namely : Carcinoma lenticulare and Carcinoma 
tuberosum. 

Carcinoma Lenticular e generally appears on the chest in 
the neighborhood of the breast, and secondary to a mam- 
mary cancer, or in the scar resulting from a previous opera- 
tion for the removal of a cancer of the breast. It appears in 
the form of smooth, firm, glistening, dull, or brownish-red 
or pinkish nodules raised above the surface, and discrete at 
first. In size the nodules vary from that of a pea to that of 
a bean. After a time the nodules run together and form a 
thick, indurated mass, which may involve so much of the 
chest as to interfere with breathing. This is the cancer en 
cuirasse of Velpeau. Now the neighboring lymphatic 
glands are involved, and the arm of the same side becomes 
swollen and useless. In a short time the nodules and the 
mass break down and ulcerate, and the patient soon dies of 
exhaustion. 

Carcinoma Tuberosum is still more rare. It may occur 
anywhere, but is most frequently seen upon the face and 
hands. It takes the form of disseminated, flat or elevated, 
round or oval tubercles or nodules, seated deeply in the 
skin and subcutaneous tissues. These are of a dull-red, viola- 
ceous, or brownish-red color. They do not tend to run 
together, but they break down and ulcerate, and the patient 
dies just as in the lenticular variety. It usually appears 
in old people. 

In both forms there may or may not be lancinating pains, 
or there may be simply itching. In both, metastasis may 
take place. 

Carcinoma Melanodes is described by most authors as 
a third form of carcinoma, but Robinson, Crocker, and 
Brocq regard it as melanotic sarcoma. It is impossible to 
distinguish them clinically from sarcoma, which see. 

Diagnosis, The diagnosis of carcinoma is not difficult 
when one is aware that there is such a disease, and knows 
that in a given case there has been, or is, a carcinoma else- 



CHLOASMA. 109 

where. The mode of evolution of the lesions, the involve- 
ment of the lymphatic glands, and the lancinating pains all 
point toward carcinoma as against a tubercular syphilide, 
lupus, or leprosy. 

Treatment. The treatment of carcinoma of the skin 
is the same as of other forms, and quite as unsatisfactory. 

Causalgia (KaVa^'jrW). Neuralgia with a sense of 
severe burning pain. 

Chair du poule. See Cutis anserina. 
Chancre. See Syphilis, initial lesion of. 

Chap. Usually a mild form of eczema or dermatitis, 
attended with superficial cracking. It is generally due to 
exposure to cold, and affects exposed parts, as the backs of 
the hands and the lips. Thorough drying of the hands 
after washing and keeping them covered from the air will 
prevent its occurrence on the hands. Avoiding wetting the 
lips, and making some greasy protecting application, such 
as camphor ice, will prevent the lips from being affected. 

Charbon. See Carbuncle. 

Cheilitis (Kil-i'-tis) glandularis is a disease of the lips, 
usually the lower one. The lip becomes gradually swollen, 
firm, and rather hard to the touch, and its mobility is im- 
paired. The mucous glands become swollen, and can be felt 
as nodular masses. A turbid muco-purulent secretion is 
poured out at times, and the gland ducts are more or less 
dilated. No pains attend the disease, which is exceedingly 
obstinate to treatment. Black wash is recommended in 
treatment, together with the occasional application of nitrate 
of silver. 

Cheiro-pompholyx. See Pompholyx. 

Chelis and Cheloide. See Keloid. 

Chilblain. See Dermatitis congelationis. 

Chloasma (Klo aVma 3 ). Synonyms : (Fr.) Chloasme, 
Panne hepatique, Tache hepatique, Chaleur du foie, Masque ; 
(Ger.) Pigmentflecken, Leberflecken ; (Ital.) Macchie epa- 
tiche ; (Eng.) Liver spot, Moth patch, Mask. 

A pigmentary disease of the skin, characterized by the 

6 



HO DISEASES OF THE SKIN. 

formation of yellowish, brownish, or blackish patches of vari- 
ous sizes and shapes. 

Symptoms. In this disease the only alteration of the 
skin is its color. The disease consists in a deposit of 
pigment in the rete mucosum, and occurs in the form of 
circumscribed or diffused patches of yellowish to black dis- 
coloration. When the color is black it is called melasma 
or melanoderma. The size of the patches varies greatly 
from a small spot up to a general bronzing of the skin. 

The disease may be primary or secondary, idiopathic or 
symptomatic. The idiopathic forms are most often second- 
ary to some irritation. Thus it occurs with or in conse- 
quence of irritants applied to the skin, whether blisters or 
even sinapisms ; prolonged scratching on account of some 
pruriginous disease such as prurigo, pruritus cutaneous, 
chronic urticaria, scabies, or pediculosis; exposure to the 
sun's rays or high winds, or even to heat, as of the furnace 
in iron-workers, and then on exposed parts. These all 
cause more or less hyperemia of the skin, and besides the 
deposit of the pigment there is more or less discoloration 
from the changes taking place in the extravasated blood. 
Allied to these causes and acting in the same way is the dis- 
coloration of the skin of the legs met with about old varicose 
ulcers, and sometimes without the ulcers when there are 
marked varicosities. 

The symptomatic form may likewise be primary or 
secondary. It is primary in that most common form of all 
that is known as Chloasma uterinum, or the mask, a form 
of hyper-pigmentation of the skin of the face that occurs 
during pregnancy, or with uterine irritation, and that is not 
met with after the menopause. It usually takes the shape 
of a diffused brownish, light or dark discoloration of the fore- 
head alone, or also about the mouth and cheeks. Usually 
it extends only across the forehead and down the temples, 
and is either a continuous or interrupted patch with sharply 
defined borders. Under the same conditions there takes 
place a deepening of the color about the nipples and along 
the linea alba. * The darkening of the color under the eyes 
of menstruating women is largely due to vascular conges- 



CHLOASMA. HI 

tion, and little if at all to chloasma. After a time in some 
women true chloasma does occur there. 

Primary pigmentation also occurs in certain cachexise, 
such as Addison's disease, tubercular leprosy in Europeans, 
abdominal tuberculosis, cirrhosis of the liver, cancer of the 
stomach, malaria, and multiple melanotic sarcoma. There 
is also an earthy look to the skin in secondary syphilis, 
as well as in congenital syphilis. Primary chloasma is also 
seen as the result of the ingestion of arsenic. Argyria is 
not a chloasma strictly speaking. 

Secondary symptomatic chloasma is seen as the sequela 
of syphiloderma, and of lichen ruber planus ; these derma- 
toses disappearing to leave behind them for a greater or less 
length of time hyper-pigmented spots. This may occur 
after other diseases of the skin, but is usually more 
fugitive. It is also seen in senile atrophy of the skin. 
There is hyper-pigmentation about the patches of leucoderma 
and in scleroderma. There is also a pigmentary syphilide 
met with upon the neck in women. 

Etiology. The cause of chloasma is undetermined in 
most cases. A late theory of the pigmentation following 
exposure to the sun is that it is due to the action of the 
chemical rays of the sun upon the constituents of the 
blood. We know also that in some cases of hyper-pigmen- 
tation the color is due to changes taking place in the color- 
ing-matter of the extravasated blood. That there is a relation 
between chloasma uterinum and the uterus we know, because 
the chloasma usually clears away either after parturition, 
the cure of the uterine disorder, or the attainment of the 
menopause. 

Diagnosis. The diagnosis is usually easy. Discolora- 
tions caused by artificial means can be washed off. Chromo- 
phytosis is scaly and can be scraped off with the nail. 
Chromidrosis is very rare, and can be washed off with 
chloroform or ether. 

Treatment. The treatment of chloasma is very unsatis- 
factory. While it is possible to remove the color, it is very 
prone to return. Acetic acid touched on in spots will 
reduce the color and sometimes remove it. The same may 



112 DISEASES OF THE SKIN. 

be said of other acids, care being used not to cause too 
great destruction of the skin by the stronger ones. The 
bichloride of mercury in 1 to 2 per cent, solution may be used 
for the purpose, applied repeatedly or else kept on continu- 
ously for three or four hours. It is not always a safe pro- 
cedure. Salicylic acid, 10 to 15 per cent., in ointment, 
paste or plaster, or in saturated solution in alcohol, may do 
well. Unna has recommended washing the part with alco- 
hol, and applying a mercurial plaster made with the ammo- 
niate of mercury over night. The next day this is to be 
removed and the following ointment to be applied : 



R. Bismuthi subnit, \ « _•„, 7 

Kaolini, J aa 3 Js f' 7 

Vaselini, gvj ad ^jss; 30 



M. 



Brocq advises a mercurial plaster during the night, bath- 
ing morning and evening with a 3 or 5 per cent, solution 
of bichloride of mercury, and wearing during the day oxide 
of zinc or bismuth ointment. 

The peroxide of hydrogen will cause a temporary disap- 
pearance of the pigmentation. In all cases where there is 
an underlying cause attention must be given first to it. 

Prognosis. Many of the symptomatic pigmentations 
disappear when the patient recovers his health. It is not 
well to promise a certain disappearance of the patches, 
as some of them are permanent. 

Chorioblastosis is any anomaly of growth of the corium 
and subcutaneous connective tissue. (Auspitz.) 
Chorionitis. See Scleroderma. 

Chromidrosis (Krom-i 2 d-ros'i 2 s). Synonyms : Ephidrosis 
tincta ; Stearrhcea or Seborrhcea nigricans ; Pityriasis nigri- 
cans ; (Fr.) Cyanopathie cutanee, Melastearrhee. 

This is a condition of the body in which the sweat has an 
abnormal color. Usually it affects only limited regions, 
especially the lower eyelids. The color is most commonly 
blue or blue-black. The subjects are most often hysterical 
women, and many of the cases are feigned. 

Besides the lower eyelids the upper ones may be 
affected. Next in frequency the colored sweat forms on 



CHROMIDROSIS. 113 

some other part of the face, but it may occur on any por- 
tion of the body. Besides the blue or black color, cases 
of yellow, green, brown, or even rosy color have been re- 
ported. A few men have exhibited the phenomenon. Hoff- 
mann 1 reports a case of blue sweat of the scrotum of a man 
seventy- two years old ; and White 2 has met with a case of 
yellow sweat in a man twenty years old. R. W. Taylor saw 
one case of apparently blue sweat that occurred in a man 
taking iodide of potassium, and was due to a reaction between 
the starch of his shirt and the iodine contained in the sweat. 
Constipation and nervous derangements are often found in 
the cases, and the chromidrosis has been noted to grow 
worse with increased constipation, and become better when 
that condition is removed ; to be more pronounced at mens- 
trual periods, and to break out suddenly under emotional 
excitement. The skin may present no appearance of change 
except the discoloration, or it may have an evident deposit 
upon it. In either case the color can be removed by wiping 
with a little oil, or scraped off partially with the finger-nail. 

Etiology. The cause of the disease is obscure. It has 
been thought to be due to the presence of colorless indican 
in the sweat, which becomes blue by oxidation. This 
accounts for a few cases at least. Most of the patients are 
hysterical women. 

Diagnosis. The diagnosis is easy, because the discolor- 
ation can be readily removed by an oiled cloth, while that 
of chromophytosis does not so readily come off, and that of 
chloasma does not yield at all. Moreover, neither of these 
last two conditions exhibits a blue color. 

Treatment. The disease requires stimulation in its 
treatment, and good results have been reported from the 
use of the following : 3 



R. Ac. borici, gr. x ; 2 

Ac. salicylici, gr. xv; 3 

Ungt. aquae rosse, Jj ; 100 

1 Wien. med. Wochenschr. , 1873, xxiii. 291. 

2 Journ. Cutan and Ven. Dis., 1884, ii. 293. 

3 Van Harlingen : Handbook of Skin Diseases. 



M. 



114 DISEASES OF THE SKIN. 

The red sweat that occurs in the axillae more especially, 
and elsewhere occasionally, is not a true chromidrosis, but 
is due to the growth of bacteria {micrococcus prodigiosus) 
upon the hair, as may readily be demonstrated under the 
microscope. The bacteria are sometimes present so abun- 
dantly as to encrust the hair. The same bacteria grown on 
culture-media are colorless, and it is supposed that the action 
of the sweat upon them determines their color. At times 
not only are the hair and skin stained red, but also the 
underclothing is deeply dyed. 

A mild parasiticide ointment or oil with the use of soap 
and water, or a simple borax solution, will cure the disease 
just as in chromidrosis. 

Green sweat has been seen in workers in copper. Yellow 
sweat has been found associated with bacteria and without 
them. 

Chromophytosis^Krom-o-fit-os'-rV). Synonyms: Pityri- 
asis versicolor ; Tinea versicolor ; Chloasma ; Mycosis 
microsporina ; (Grer.) Kleien Flechte ; (Fr.) Pityriasis 
parasitaire. 

A vegetable parasitic disease, characterized by brown or 
cafe-au lait colored, variously shaped and sized patches that 
occur chiefly upon the trunk. 

This disease is far more common than statistical tables 
show it to be, as it causes so little trouble that many people 
never think of applying for relief. It begins as a small 
yellowish point, which rapidly grows into a split-pea-sized 
lesion. Many new lesions appear, and these coalescing, 
patches form which may be so large as to occupy a great 
part of the chest or back. At first, when of small size, the 
patches are circular in shape, but as they grow larger they 
lose all definiteness of shape, though their edges are always 
sharply marked and sometimes raised. Annular patches 
sometimes form, and at other times there will be many more 
or less circular patches of sound skin in the midst of the 

1 The name of chromophytosis was proposed for this disease by Dr. 
F.P. Foster, and has been well received in New York, as it quite accu- 
rately defines the disease, and brings it in line with trichophytosis. 



CHR0M0PHY10SIS. 115 

diffused patch. The color is usually fawn or cafe-au-lait; it 
may be brown, or even black. The latter is reported only 
from tropical countries. In warm weather and in those who 
sweat profusely it is no uncommon thing to see the eruption 
present a pinkish hue, due to hyperemia of the skin. The 
edge of the patch may be somewhat raised, but the surface 
is not generally above that of the skin. It presents various 
appearances. At times it is smooth and feels greasy ; at 
times it is dry and covered with fine branny scales ; while 
at times it looks rough, and viewed in the proper light it 
presents an appearance resembling that of ichthyosis of mild 
grade. These appearances are dependent upon the amount 
of sweating, which, if profuse, will remove the scales, espe- 
cially if the clothing rubs upon the skin. The greasy feel 
is imparted by the oily sebaceous matter always marked in 
the region of the sternum, where chromophytosis most often 
is located. Whatever may be the apparent condition of the 
surface, scraping with the nail will remove a good part of 
the disease, showing that it is located in the upper layers of 
the epidermis. These patches are located chiefly upon the 
anterior surface of the chest and upon the abdomen. The 
back is also quite often affected, but not so markedly as the 
chest. In very extended cases the arms and legs may show 
the disease, and a few cases have been reported as occurring 
upon the face. The rule is that the uncovered parts of the 
body are spared, and exceptions to this are very rare. It 
is not symmetrical. The number of patches varies from a 
few to hundreds. 

The only subjective symptom is itching, and this is often 
absent, and seldom so bad as to cause the patient to seek 
relief on that account. Patients desire to be treated on 
account of the deformity, not the discomfort, of the disease. 

Etiology. The cause of the disease is the lodgement and 
growth in the corneous layer of the skin of a vegetable 
parasite, the microsporon furfur. Like all other parasites 
of its class, this one is incapable of growth on every skin, 
but does flourish especially upon the skin of one who 
sweats freely. That consumptives were thought to be espe- 
cially prone to the disease is due to the fact that their chests 



116 DISEASES OF THE SKIN. 

are exposed to the physician more often than are those of 
any other class of patients. The disease is contagious, but 
its contagion is of low grade, and it is not common for it to 
take place even in such intimate relations as obtain between 
husband and wife. Adults from twenty to forty years of 
age are the most common subjects, though children have 
had the disease. According to Besnier and Doyon, the dis- 
ease is never seen in very old people. It occurs in all coun- 
tries, but most often in hot climates. It attacks all classes 
and conditions of men, and shows no particular discrimina- 
tion in regard to sex. Its growth is interrupted by malarial 
paroxysms, and it peels off with the desquamation of scar- 
latina and measles. 

Pathology. The microsporon furfur is one of the most 
readily demonstrated of parasites. Place a few scales upon 
the slide, add a drop or two of liquor potassse, tease out the 
material a little, put on the cover-glass, and even with a low 
power the picture here represented will be seen (Fig. 13). 
It consists of heaps of conidia, which are larger than those 
of ringworm, with any quantity of interlacing mycelia run- 
ning between them. Free conidia are scattered about in the 
field. The fungus grows in the upper layers of the epider- 
mis. It has been asserted that there were two kinds of 
fungus, one brown and the other pale red, each of which 
produces its own colored eruption. 

Diagnosis. If one remembers the characteristic feat- 
ures of the disease, yellow or cafe-au-lait, scaly patches, 
that can be partly scraped away and are located chiefly 
upon the chest, little difficulty can arise in diagnosis. An 
appeal to the microscope will decide any doubtful question. 
Chloasma is not scaly, and cannot be scraped off from the 
skin. Leucoderma is an absence of pigment with a hyper- 
pigmentation about it that comes up to the white spot with 
a concave border, and is not scaly. A fading erythematous 
syphilide occurs not in patches, but in isolated round mac- 
ules that are neither scaly nor itchy, that are usually most 
numerous over the abdomen and sides of the chest, and that 
are very often found as a disseminated eruption occurring 
upon the face as well as the trunk. Erythrasma is not so 



CHR OMOPHYTOSIS. 



117 



scaly, and occurs only in or about the joints. Its parasite 
is much smaller than that of chromophytosis. 



Fig. 13. 




Microsporon furfur. (After Kaposi.) 

Treatment. Anything that will cause the removal of 
the upper layers of the epidermis will cure chromophytosis 
when present only to slight degree. But it is best for safety 
to use a parasiticide. One of the pleasantest ways of cur- 
ing the disease is to have the patient scrub his skin thoroughly 
with soap and water, preferably soft-soap, and then dab on, 
twice a day, a saturated solution of hyposulphite of soda. 
Sulphurous acid, pure or dilute, is a prompt remedy. Vlem- 
inckx's solution, one to three or six parts of water ; bichlo- 
ride of mercury, two or three grains to the ounce ; sulphur 
ointment rubbed in thoroughly ; and tincture of veratrum 
viride, are efficacious. The danger of systemic poisoning 
by either the bichloride of mercury or the veratrum viride 
should deter us from using these remedies in extensive cases. 
Unna 1 recommends : 

1 Vierteljalirschr. Derm. u. Syph., 1880, vii. 166. 
6* 



118 DISEASES OF THE SKIN. 

R . Tinct rhei aquosse, j -- M 

(rlycerini, J r 

Brocq gives the following : 

R. Acid, salicylici, 2-3 parts. 

Sulphur, prsecip , 10-15 " 

Lanolini, 70 " 

Vaselini, 18 ll M. 

Chrysarobin, naphthol, boric acid, and resorcin, all are 
good. If the disease is very limited, it can be surely and 
speedily destroyed by painting the spot with tincture of 
iodine. 

There is only one point to be borne in mind in using any 
of these remedies, and that is, that they must be thoroughly 
used, and continued for a time even after the last trace of 
the fungus seems to have been removed. If one spore is 
left behind, the disease is liable to return. Relapses are 
common, as the patient's skin is susceptible to the lodgement 
of the fungus. 

Clastothrix. See Trichorrhexis nodosa. 

Clavus (Kla'vu 3 s). Synonyms : (Fr.) Cor ; (Ger.) 
Leichdorn, Hiihnerauge ; Corn. 

Symptoms. Corns are hyperplasias of the corneous 
layers of the skin due to pressure, and differing from cal- 
luses in having a central core that grows down toward 
the corium. They occur usually upon the toes, either over 
prominent joints, where they form hard corns, or between 
the toes, where, on account of being kept moist, they form 
soft corns. They are usually conical in shape, and slightly 
projecting. Unless pared down they become painful by 
being pressed into the cutis. They are sometimes sponta- 
neously painful on the approach of wet weather on account of 
their being hygroscopic. They may suppurate. They may 
occur upon the palms; I have seen several cases in tennis- 
players. The soles are sometimes affected with them, and 
then walking is rendered very painful. 

Treatment. The best treatment for corns is to wear 
well-fitting boots and shoes, which must not be too large or 
too small. The corn may be removed by the use of a sali- 



COLD SORE. 119 

cylic acid plaster, or by Vigier's preparation, now sold in all 
the shops under the name of Hebra's Corn Remedy, which 
is composed of — 



11. 


Ac salicylici, 


gr. xv. 




Ext. cannabis indicse, 


gr. viij. 




Alcoholis, 


Hlxv. 




Etheris, 


m*i. 




Collodion flex., 


1H lxxv. 



M. 

which is to be painted on three times a day for a week ; 
then the feet are to be soaked in hot water, and the corn 
picked out. They may also be cut out, but the operation is 
at times dangerous, especially in old people. Resorcin 
plaster of ten per cent, strength worn for some days will 
remove corns. Crocker recommends for soft corns careful 
daily ablution with soap and water, painting on them spirits 
of camphor at night, and wearing wool between the toes 
during the day. But unless well-made boots are worn, the 
corns will be sure to return. Corns on the hands may be 
removed with salicylic acid, or scraped out with the dermal 
curette. 

Clavus Syphiliticus. Under this title Lewin 1 describes 
certain lesions that he regards as being syphilitic. They are 
horny elevated growths that occur upon the hands and feet, 
and are sometimes surmounted by a delicate scaly crown, 
and sometimes covered with scales. They are from pin- 
head to lentil sized, circular, oval, or oblong in shape ; flat 
or concave on top, but never convex, and appear as if 
wedged into the skin. At first they are pale red and soft, 
but later they become yellowish horn-color and hard. They 
are usually on the palms of the hands, but may be on the 
soles of the feet, as well as upon all surfaces of the fingers 
and toes. There is no pain caused by them. There may 
be some itching. The lesions are met with in both sexes, 
and occur early in the disease, and often symmetrically. 

Cnidosis. See Urticaria. 

Cold Sore. See Herpes facialis. 

1 Arch. Derm u. Syph., 1893, xxv. 3. 



120 DISEASES OF 1HE SKIN. 

Colloid degeneration of the skin. Synonyms: Colloid 
milium ; (Ger.) Hyalom der Haut ; (Fr.) Hyalome cutane\ 

Symptoms. This is a very rare disease of the skin that 
occurs most often on the upper part of the face in the form 
of disseminated or grouped, discrete, transparent, shining, 
rounded, lemon-yellow elevations of the skin. Though they 
look as though they were vesicles, they do not contain fluid, 
and when pricked give exit to only a small amount of 
gelatinous substance and a drop or two of blood. They are 
resistant to the touch. The course of the disease is slow. It 
is capable of spontaneous disappearance by absorption or 
inflammation, leaving an ill-defined mark on the skin. It 
affects both sexes. The youngest patient so far reported 
was fifteen years old. There are no subjective symptoms, 
and the general health is good. 

Diagnosis. It differs from xanthoma in the transpar- 
ency and shining appearance of the lesions and in their 
lemon-yellow color. In xanthoma the lesions are soft and 
of a dull yellow. In hidrocy stoma the lesions are more 
crystalline in appearance, and when pricked a drop of pure 
fluid escapes from them. 

Treatment consists in removing them by the curette 
or electrolysis. 

Comedo ( KoWe 2 d-o). Synonyms: Acne punctata, 
Acne follicularis ; (Fr.) Comeclon, Acne puncture, Tanne ; 
(Ger.) Mitesser, Hautwiirmer ; Grubs, Fleshworms, Black- 
heads. 

A comedo is a collection of inspissated sebaceous matter 
retained in a pilo-sebaceous gland, whose mouth is closed by 
a brown or black-topped plug of extraneous matter, and ap- 
pears as a pin-point to a pin-head, slightly elevated, conical 
papule in the skin. 

Symptoms. Comedones are met with most often upon 
the face, ears, back, and shoulders, and occasionally, but 
much more rarely, on other parts of the body. Wherever 
met with they present the characteristics indicated in the 
definition just given. They are unaccompanied by inflam- 
matory symptoms. Just as soon as inflammation is caused 



COMEDO. 121 

by their presence, they are converted into acne lesions — a 
change that they very commonly undergo. Usually they 
are scattered about irregularly ; sometimes they are grouped 
in certain regions. They are single lesions in the vast 
majority of cases, and being pressed between the thumb- 
nails they are readily expressed in the form either of an 
ovoid mass or more commonly as a filiform or worm-like 
mass that may be a half-inch or more in length, and has a 
black head that obtains for them the popular name of "flesh- 
worms." Very exceptionally they are double, lateral pres- 
sure squeezing out a filiform mass with a black head at both 
ends, if such an expression is allowable. There may be but 
few, or there may be hundreds of them so that the face looks 
as if full of grains of gunpowder. The largest are found 
in the ears and on the back. They give rise to no subjec- 
tive symptoms. Seborrhoea oleosa is frequently a marked 
complication. 

In children they are more apt to be grouped, and, ac- 
cording to Crocker, to appear on the foreheads and occiput 
of boys, the temples in girls, and the cheeks in infants. 
The scalp, too, is in them the seat of the disease. Acne 
may follow them. 

Etiology. All that has been said as to the causes of 
acne applies with equal force to comedones, and need not 
be repeated here. We would only add that Unna does not 
accept the commonly received doctrine that the black head 
and the clogging of the follicle are largely due to extra- 
neous matter, but teaches 1 that they are due to the corneous 
layer of the skin being abnormally firm, and preventing 
the escape of the follicle contents by growing over its mouth. 
The black color he believes to be analogous to the coloration 
of horns in cattle. He calls attention to the fact that 
comedones are more frequent in chlorotic girls than in coal- 
heavers. 

It is quite certain that many cases of comedones are 
directly due to dirt or other foreign matters stopping up the 
follicles. This is supposed to be especially the case in chil- 

1 Virchow's Archiv, 1880, lxxxii. 175. 



122 



DISEASES OF THE SKIN. 



dren. Colcott Fox 1 says that in them the comedones are 
found most often in the spring-time, and disappear in the 
winter. The youngest case in a child is one at twelve 
months. 2 

Pathology. The pathology of the affection is the same 
as that of acne without the evidence of inflammation. The 
demodex foUiculorum, a harmless parasite, is very often 

Fig. 14. 




DemodexTolliculorum. (After Kuchenmeister.) 

found in the plugs of sebaceous matter. This is long and 
worm-like, with a head ; a thorax with four pairs of short, 
conical, three-jointed feet, with minute claw-like extremi- 
ties, and a long tail-like abdomen, which tapers off into a 
blunt and rounded point. (Fig. 14.) 



Lancet, 1888, i. 665. 



2 Crocker: Lancet, 1884, i. 704. 



COMEDO. 



123 



Von During 1 has endeavored to show that the double 
comedo is always an acquired formation, and is the result 
of a destructive process between the ducts of two neighbor- 
ing glands, so that the two ducts become one, and that the 
destructive process has affected only one gland, while the 
other one is still active enough to produce the comedo plug. 

Diagnosis. There is little difficulty in recognizing the 
disorder. Powder grains in the skin are under the skin, 
and cannot be squeezed out. 




Piffard's comedo-extractors. 

Treatment. The same constitutional conditions being 
met with in comedones as in acne, we need not repeat here 
what was said there in regard to their general treatment. 

The local treatment consists in pressing out the come- 
dones and stimulating the skin to a more healthy action. 
There is little use in doing the first without the second, as 
the comedo would be sure to re-form. The comedones come 
out most readily after the free use of soap and warm water. 
Then they may be pressed out between the thumb-nails, or 

Fig. 16. 



Fox's comedo-scoop. 

by means of an old watch-key, whose sharp edges have been 
worn down ; or by means of either of the comedo-pressers 
of Piffard (Fig. 15), or the comedo-scoop of Fox (Fig. 16). 
With some practice they may be removed by pressing the 

1 Monatshefte f. p. Dermat., 1888, vii. 401. 



124 DISEASES OF THE SKIN. 

backside of a small dermal curette against one side of the 
follicle mouth, and making a quick turn of the end about 
them. Yiolent attempts at removal should not be made, as 
they may cause inflammation on account of too much irrita- 
tion. If the comedo does not come out readily, wait until 
another time. 

Frictions with green or soft soap and water are excellent 
as a stimulating remedy, care being taken not to set up too 
much reaction. Hardaway recommends : 



R . Saponis olivse preparat. , \ - . z • 1A 

Alcoholis, / aa 3JI A»> 

Aquse rosse, § vj ; 100 



M. 



To be rubbed in with a piece of dampened flannel every 
night. He regards the use of sulphur preparations as tend- 
ing to cause comedones, and hence objectionable. Alcoholic 
and astringent lotions, of boric acid, alum, or zinc, are 
useful. 

Sulphur and most of the preparations given under Acne 
have their advocates here. 

The best prophylactic measure is the daily washing of the 
face with soap and water. 

Condyloma. See Verruca and Syphilis. 

Congelatio. See Dermatitis calorica. 

Corn. See Clavus. 

Cornu Cutaneum vel Humahum. Synonyms : (Fr.) 
Corne de la peau ; (Ger.) Hauthorn ; Cutaneous horn. 

This is a rare disease of the skin, in which there grows a 
horn-like excrescence resembling, often in a most striking 
manner, an animal's horn. These vary greatly as to size. 
They may attain the length of a foot and a diameter of four- 
teen inches at the base, and are usually single, but may be 
multiple. They may be straight, but usually are bent or 
twisted; they may be laminated, striated, or fibrillated ; 
they may be yellowish, dirty gray, green, brown, or black ; 
they are solid and hard, but not smooth and shining like 
animals' horns often are; and they have rounded or trun- 
cated ends. They are not painful unless pressed on. When 



CYSTICERCUS CELLULOSJE CUTIS. 125 

torn or knocked off they expose a raw and bleeding surface. 
Sometimes they fall spontaneously, or as the result of some 
inflammatory process. Most of them occur upon the head, 
nose, face, or scalp. They may occur elsewhere, as upon 
the extremities, or male genitals. Their bases may become 
the site of epithelioma. 

There is little known about their etiology. They may 
occur at any age and in either sex. They seem to be warty 
growths that have undergone corneous transformation. 

Treatment. The treatment consists in tearing them off, 
under an anaesthetic if large, curetting the base, and apply- 
ing a caustic agent, such as a chloride of zinc paste or pyro- 
gallic acid. 

Couperose. See Rosacea. 

Crasses Parasitaires. See Chromophytosis. 

Crusta Lactea. See Eczema. 

Cutis Anserina, or Groose-flesh, is that condition of the 
skin in which, on account of the action of cold causing a 
contraction of the arrectores pilorum muscles and elevation 
of the hair follicles, it feels rough, and looks as if studded 
over with minute papules. It is a fugitive affair, therein 
differing from keratosis pilaris, which, though resembling it, 
is constant. 

Cutis Pendula. See Dermatolysis. 

Cutis Tensa Chronica. See Scleroderma. 

Cutis Unctuosa. See Seborrhcea. 

Cyanosis (Si-a 2 n-os'i 2 s) is a bluish coloration of the skin 
from defective aeration of the blood, either temporary, as in 
asphyxia, collapse, etc., or permanent, as in the subject of 
some malformation of the heart, especially persistent patency 
of the foramen ovale. 1 

Cysticercus Cellulosae Cutis. At times the larvae of the 
tapeworm become lodged in the subcutaneous tissues, and 
produce movable, painless, round or oval, pea- or cherry- 
sized tumors, with the skin raised over them. They are 

1 Foster's Encyclopaedic Medical Dictionary. 



126 DISEASES OE THE SKIN. 

smooth, firm, and elastic. The larger ones may feel like 
wens. After about eight months (Cobbold) the animals die, 
and the tumors shrivel up and become hard nodules, or they 
may be absorbed. They simulate gummas, lipomas, sar- 
comas, carcinomas, and sebaceous cysts. In a doubtful case 
excision or puncture of one of the tumors will show us 
under the microscope either one of the larvae curled up in 
its shell, as it were, or the hooklets in the fluid that 
escapes. 

Cysto-adenoma is an adenoma containing cysts. 
Dandriff or Dandruff. See Seborrhoea. 
Dartre Farineuse, Furfuracee, or Volante. Old terms 
for Pityriasis and Eczema. 

Dartre Rongeante. See Lupus vulgaris. 

Dartrous Diathesis. This term, though still used by 
French writers, is of very indefinite meaning, and has been 
dropped by their latest author, Brocq. Dunglison defines 
it as "a peculiar state of health, which renders its subject 
liable to general eruptions of different forms, which are 
always met with in the young, are symmetrical, and con- 
trolled by arsenic.'' It is supposed to be the underlying 
cause of eczema, herpes, seborrhoea, psoriasis, and not a few 
other diseases. 

Decrepitude Infantile. See Sclerema neonatorum. 
Defluvium Capillorum. See Alopecia. 
Defoedatio Unguium. See Nails, degeneration of. 
Delhi Boil. See Aleppo boil. 

Dermatalgia (Du 5 rm-a 2 t-a 2 l'ji 2 -a 3 ). Synonyms : (Fr.) 
Dermalgie ; (Ger.) Hautschmerz ; Hautnervenschmerz ; 
Neuralgia or rheumatism of the skin. 

By this term is meant spontaneous pain in the skin, with- 
out any appreciable alteration of the same. The pain is 
variously described by patients as boring, pricking, or burn- 
ing ; or numbness or coldness may be complained of. It is 
constant or intermittent in character, and sometimes so 
severe as to be agonizing. It is generally sharply located 



DERMATITIS. 127 

to a certain place, but it may be general. The hairy parts 
are those most often affected, as the scalp. The legs and 
back, palms aud soles, are also not infrequently involved, 
as may be any part. Hyperesthesia or anaesthesia may 
be present at the same time. Deep pressure may or may 
not relieve it. It disappears of itself after weeks or months. 

Etiology. It is a neurosis that may be idiopathic or 
symptomatic. The idiopathic form is rare, and its etiology 
obscure. The symptomatic form occurs in locomotor ataxia, 
rheumatism, syphilis, malaria, diabetes, hysteria, chlorosis, 
and after zoster. According to Hyde, it may be a sign of 
the approaching menopause. The majority of its subjects 
are women. 

Diagnosis. Dermatalgia differs from neuralgia in being 
more superficial and in being accompanied by hypersesthesia. 
It differs from hyperesthesia by being a spontaneous pain, 
while the latter is pain only upon contact. 

Treatment. If we can remove the underlying cause, we 
shall cure the trouble, so our remedies should be first ad- 
dressed to it. Unfortunately, for some of the diseases of 
which dermatalgia is a symptom we can do little. In 
any case, the patient demands some local treatment to 
relieve the pain. In the way of internal remedies we can 
use salicylate of soda, quinine, antipyrin, phenacetine, some 
form of opium, hyoscyamus, valerian, and other like drugs. 
Externally, relief may be obtained by galvanism, blistering, 
a mustard leaf over the centre from which emanates the 
nerve (Crocker), hot or cold water in a rubber water-bag, 
either alone or alternately ; rubbing in Squibb's oleate of 
mercury or morphine, menthol pencil, chloroform liniment, 
tincture of aconite, and the like. 

Dermatitis (Du 5 rm-a 2 t-i /2 s). This word means simply 
inflammation of the skin, and would, therefore, cover all 
diseases of the skin that are of inflammatory nature. But 
it is applied to those diseases of the integument that are 
simple inflammations, and due to the action of external 
irritants. They are all marked by redness, swelling, and 
heat. The name dermatitis, with a qualifying adjective, is 



128 DISEASES OF THE SKIN. 

also applied to diseases other than those in this section, as 
will be seen further on. 

Dermatitis Bullosa. See Epidermolysis. 

Dermatitis Calorica is the inflammation of the skin pro- 
duced by heat or cold, and divides itself naturally into two 
divisions, viz. : D. ambustionis and D. congelationis. 

Dermatitis ambustionis is the effect of heat upon the 
skin, the source of the same being either natural, as from 
the sun, or artificial. According to the intensity and pro- 
longed action of the heat and the resistance of the skin will 
be the damage inflicted on the skin. A slight degree of 
heat gives rise to a passing erythema. Burns are due to a 
greater amount of heat, and are described for convenience 
as being of three degrees. In the first degree the skin is 
reddened, hot, and somewhat swollen ; in the second the 
damage is greater, and we have the production of vesicles 
and bullae ; and in the third there is complete destruction 
of the skin, followed by gangrene. There is always con- 
siderable pain with any burn, and if of great extent we have 
rise of temperature and shock. Extensive burns may be 
dangerous to life even if not of very high degree, and burns 
involving one-half the cutaneous surface are generally fatal. 
The cause of death in such cases is uncertain. One theory, 
as put forth by Lustgarten, 1 is that it is due to a toxin 
developed by the lodgement of micro-organisms of putrefac- 
tion upon the eschar, probably a ptomaine similar to 
muscarin. Some of the other theories are nerve-shock, 
ulcerations of digestive tract, nephritis, decomposition of the 
red blood-globules ; but no one of these is satisfactory in all 
cases. 

Treatment. The treatment of severe burns commonly 
falls into the hands of the surgeons. In simple burns the pain 
may be relieved by painting them with a five to ten per 
cent, solution of cocaine, and then applying Carron oil, con- 
sisting of equal parts of linseed oil and lime-water, to which 
may be added 5 per cent, of carbolic acid, by means of 

1 Med. Bee, 1891, xl. 152. 



DERMATITIS CONGELATIONIS. 129 

saturating absorbent cotton in it, and then covering it with 
impermeable rubber tissue. This forms an admirable dress- 
ing that may be left on for several days, if care is taken to 
disinfect the part thoroughly before applying it. If this is 
not at hand, the part should be dusted thickly with flour or 
corn-starch until it is procured. Or the burns may be cov- 
ered with a varnish of linseed oil and wax, containing 5 per 
cent, of salicylic acid. Or they may be powdered with bicar- 
bonate of soda or any of the antiseptic powders. Deep and 
extensive burns must be treated on surgical and strictly an- 
tiseptic principles. Lustgarten, in the paper referred to, 
recommends the administration of atropine as a physiologi- 
cal antagonist to the ptomaine, the removal of necrotic por- 
tions of skin, and dressing the wound with carbonate of 
magnesia, 1 part, and oleum rusci, 2 parts. All cases of 
any magnitude demand absolute rest in bed. The con- 
tinuous water-bath of Hebra is excellent where it can be 
had. 

In sunburn the application of cold cream and a dusting- 
powder is usually sufficient. As a preventative the skin 
may be anointed with the grease paint used by actors, pre- 
ferably one of brown color. Or a calamine lotion may be 
used freely. 

Dermatitis congelationis or " frostbite " is the action of 
cold upon the skin. Like heat, cold produces varying de- 
grees of damage to the skin ; if not very intense, the effect 
is an erythema — " erythema pernio, '' " chilblain ? ' — which 
is passing. These are seen upon the hands, feet, and face 
as bluish or purplish-red, circumscribed patches, which are 
cool to the touch, but are accompanied by a feeling of heat, 
smarting, or burning, both while forming and when the 
parts again become warmed. To those predisposed to chil- 
blains, dampness accompanied by only very moderately cool 
temperature is sufficient to produce them. Hutchinson 
speaks of the chilblain diathesis to indicate the condition 
found in these people. Their circulation is poor, and they 
are anaemic. Greater degrees of cold at first cause the parts 
to look white, dead, and wrinkled. When the cold is less- 
ened redness and swelling supervene. Longer exposure 



130 DISEASES OF THE SKIN. 

may produce bullae and vesicles, or gangrene, either on 
account of prolonged anaemia or inflammatory reaction from 
too sudden warming. Fingers, toes, nose, or ears may be 
lost in consequence, mortification setting in. Death may 
result from septicaemia. 

Treatment. The best preventive treatment of chilblains 
is the wearing of warm woollen coverings to the affected 
parts, and endeavoring to improve the general health of the 
patient and to quicken his circulation. To the latter end 
we may use warm foot-baths, containing salt, at night, fol- 
lowed by frictions with alcohol. When they occur stimula- 
tion is necessary, for which we may use iodine, either in 
tincture or ointment ; or equal parts of camphor and bella- 
donna liniment ; or — 



£.01. cajiputi, 1 ... g 

Liq. ammon fort , J o J > 

Sapo. liniment, co., ^iij ; 100 



M. 



or simple frictions. Care should be taken in severe frost- 
bites not to allow the parts to become warm too rapidly, and 
nothing is better than rubbing them with snow, if that can 
be obtained, while the patient is kept in a cool room. When 
sloughing or ulceration is begun it must be treated on sur- 
gical principles. 

Dermatitis Contusiformis. See Erythema nodosum. 

Dermatitis Epidemica. Under this name Savill 1 has re- 
ported the occurrence, in Paddington Infirmary, of a num- 
ber of cases of an apparently contagious disease of the skin, 
that began either as a discrete papular eruption, or as ery- 
thematous blotches like erythema nodosum or papulosum, 
or as small, flat papules enlarging at the periphery and 
spreading like ringworm. This stage lasted three to eight 
days. It was followed by the second stage, which was one 
of exudation or desquamation, and lasted three to eight 
weeks. However the disease began, the lesions soon ran 
together and formed a crimson surface of thickened and in- 
durated skin, continually shedding its cuticle in scales or 

1 Brit. Journ. Dermat, 1892, iv. 35. 



DERMA TITIS EXFOLIA TIVA. 131 

flakes of various sizes, sometimes mingled with drier exuda- 
tion. In the second stage it assumed either a moist type, 
like eczema madidans, or a dry one like pityriasis rubra. 
About two-thirds of the cases were of the moist variety, and 
almost all at some period showed slight moisture, either 
in the flexures of the joints or behind the ears. Continu- 
ous exfoliation was present in all the cases. 

The third stage was one of subsidence. By degrees the 
inflammation lessened, leaving an indurated, thickened skin, 
with polished brown appearance, which was sometimes raw, 
or parchment-like, smooth and shiny, or cracked, or pur- 
puric, especially in aged people. 

The disease began most often in the skin-folds of the face 
and upper extremities, and involved either the whole body 
or limited areas. It generally spread by continuity. The 
hair and nails were all shed. 

The constitutional symptoms were anorexia and prostra- 
tion. There was either no change in the body-temperature 
or a slight rise in the evening during the height of the dis- 
ease. Itching and burning were marked, and there was 
considerable suffering experienced in those cases in which 
the epidermis was shed. Relapses were frequent. Albu- 
minuria was found in half of the cases, and death occurred 
in about twelve and four-fifths of the cases. 

More men than women were attacked, and advanced age 
predisposed to it. A specific microorganism is thought to 
have been found in it. 

Clinically these cases resemble dermatitis exfoliativa, an 
instance of the contagion of which I have once met with. 
Its proper place has not been determined as yet. 

Dermatitis Exfoliativa. Synonyms : Pityriasis rubra 
(Devergie and Hebra) ; Eczema foliaceum seu exfoliativum ; 
(Fr.) Dermatite exfoliatrice ou exfoliative generalised, Herpe- 
tide exfoliative, Erythrodermie exfoliante. 

An inflammatory disease of the skin involving the whole 
cutaneous surface, and characterized by redness, dryness, 
and abundant desquamation. 

The terms dermatitis exfoliativa and pityriasis rubra are 
used interchangeably by most authorities of the present time. 



132 DISEASES OF THE SKIN. 

If one reads the description of pityriasis rubra, as given by 
Hebra, and of dermatitis exfoliativa, as given by Wilson, he 
will find that the chief difference between them is in prog- 
nosis, the first being spoken of as uniformly fatal, and the 
second as tending to recovery in many instances. Further, 
there are not a few cases of general exfoliating dermatitis 
that follow psoriasis, eczema, pemphigus foliaceus, and 
lichen ruber, that present symptoms identical with those 
of dermatitis exfoliativa, without antecedent disease. It 
seems justifiable, therefore, to divide dermatitis exfoliativa 
into two varieties, namely, a primary and a secondary. 

1. Primary Dermatitis exfoliativa or Pityriasis rubra of 
Hebra. 

Symptoms. This disease begins as one or more erythe- 
matous patches in the folds of the joints, upon the upper part 
of the chest or elsewhere, and these patches gradually en- 
large. At the same time new patches develop, and increas- 
ing in size join the original ones. In this way the whole 
surface may become red within three days, or a month or 
more may elapse before the whole surface is implicated. 
The palms and soles may be unaffected for days or weeks. 
The skin is dry, and of a bright red at first, without thick- 
ening and infiltration, the redness lessening and leaving a 
yellow stain on pressure. In a few days, say from six to 
twelve, scaling begins, and the skin becomes of a darker 
red ; it may even become violaceous. The scales may be 
large, thin, grayish, attached at their upper border, and 
loose elsewhere, being turned up at their edges. They may 
be small and adherent in the centre. The amount of scal- 
ing is so great that handfuls of scales may be gathered from 
the bed after a night's rest. After a few weeks the epider- 
mis is raised and shed from the hands and soles in the form 
of a continuous sheet, sometimes forming a complete cast of 
the part. There is a marked enlargement of the glands in the 
groin so that the whole packet of glands stands out promi- 
nently against the red skin. The disease is chronic, and 
the scaling constant, though marked with exacerbations. 
After lasting some time, there is a certain amount of infil- 
tration of the skin, and it seems to grow too small for the 



DERMATITIS EXFOLIATIVA. 133 

body, and looks stretched and shiny in places. Thus are 
produced ectropion and a puckered condition of the mouth. 
We may also find cracking about the joints and moisture 
in these regions. Furuncles, bullae, or pustules may com- 
plicate matters. The hair may be shed from all parts, and 
the nails become raised from their beds and shed. The 
mucous membranes participate in the disturbance, the tongue 
becomes markedly red, the lips cracked, and the nasal secre- 
tions are increased. With the ectropion there is conjunc- 
tivitis. 

The disease begins, in some cases, with a chill, followed 
by a fever that may rise to 104° F. Fever is present in 
all cases during the early period, and may continue through- 
out. It is sometimes continuous, with evening exacerba- 
tions ; at other times it is only at night. Diarrhoea often 
is met with, and there may be vomiting, albuminuria, and 
pulmonary congestion. The patient complains of a feeling 
of chilliness, and of pain, tenderness, stinging, burning, or 
tingling of the skin. There is usually no itching. The 
sensibility of the skin is preserved, and the secretion of 
sweat may be normal, or lessened, or increased. The dura- 
tion is very variable. Recovery may take place in six 
months or a year, or the course may be chronic, the patient 
dying either in a few months or after years by a gradual 
marasmus, though the end is usually hastened by pulmonary 
complications. 

Cases of localized dermatitis exfoliativa have been re- 
ported, but they are rare. The tendency is for the disease 
to become general, though it may take years to do so. Cases 
of a recurrent type have been met with. 

Etiology. We know very little about the causes of the 
disease. It is a disease of adults, and more common in men 
than in women. It may occur in children. It has been 
thought to be predisposed to by alcoholism, gout, and 
rheumatism. An attempt has been made to trace a re- 
lationship between it and general tuberculosis. There 
may be a history of scaling skin diseases in the family. 
At present we cannot speak with any certainty as to its 
etiology. 



134 DISEASES OF THE SKIN. 

2. Secondary Dermatitis Exfoliativa. A condition- of the 
skin exactly resembling the primary form is seen from time 
to time to follow upon or develop from a psoriasis, eczema, 
pemphigus foliaceus, and lichen ruber. I have seen one 
case follow lichen planus. The too vigorous use of chrysa- 
robin has been known to be followed by it. These cases 
differ from the primary form only in their antecedent skin 
disease. Once developed they run the same course as the 
primary form, either becoming well quickly, or falling into 
a chronic state from which recovery may or may not take 
place. The prognosis is, however, much better in the 
secondary than in the primary form. 

Crocker states that the disease may occur in children, 
though it is very rare. In them it runs a more acute 
course, and is attended by severe constitutional symptoms. 
It is usually of the secondary variety. 

Pathology. Histological examination shows that the 
disease is a dermatitis, quite superficial at first, but when it 
has lasted some time the whole depth of the skin is involved, 
and eventually there is new connective-tissue formation, 
which subsequently undergoes cicatricial contraction, with 
abundant pigmentation, hyperplasia of the elastic fibre 
bundles, and obliteration of the skin appendages. (Crocker.) 

Diagnosis. When the features of the disease, as laid 
down in the definition, are remembered, there should be no 
difficulty in recognizing it. No other disease involves the 
whole surface in a uniform dry and scaling redness. It dif- 
fers from psoriasis in being universal, in an entire absence 
of thick, silvery-white scales, and in leaving a smooth, red 
surface when its papery scales are removed. Should it be 
secondary to a psoriasis, there will be no difficulty in ob- 
taining a history of that disease. It differs from eczema in 
being a dry disease, with little infiltration, in its large papery 
scales, and in itching but slightly. Eczema may be almost 
universal, but some places are apt to be spared ; there is 
always moisture of a sticky sort present somewhere, or a 
history of the same ; its scales are small, and its itching in- 
tense. It differs from pemphigus foliaceus in an absence 
of flaccid bullae. It differs from lichen ruber in an entire 



DERMATITIS EXFOLIATIVA. 135 

absence of papules, and in the whole course of the disease. 
All these diseases may be general, but it is exceedingly rare 
for them to become universal, and it is always possible to 
obtain a history of their having been present at some time 
in a case of secondary dermatitis exfoliativa. It is hardly 
likely that scarlatina could be confounded with dermatitis. 
A few days' watching would in any event decide the ques- 
tion. 

Treatment. The results of treatment of this disease 
leave much to be desired. Many internal and external 
remedies have been tried, but they all are of very uncertain 
value. There is no doubt that the patient is most com- 
fortable when the skin is well oiled, and vaseline of good 
quality answers well for this purpose. The general health is 
to be watched over, iron and quinine administered, and care 
exercised to preserve the strength by judicious feeding with- 
out stimulation. Diuretics may be given with the idea of 
relieving the congestion of the skin. Carbolic acid has 
been recommended, but in my hands proved worse than 
useless in one case. Pilocarpine, or jaborandi, is recom- 
mended by Hardaway in acute cases. Arsenic should not 
be given till late in the disease, if at all. Crocker recom- 
mends enveloping the body in calamine lotion, and giving 
bicarbonate of potash every four hours in twenty-grain 
doses, with twelve grains of citric acid and three to five 
grains of quinine, the whole taken while effervescing. Sher- 
well has reported several cases cured by the continuous use 
of linseed oil, both internally and externally. The patient 
is to chew or take in milk several ounces of flaxseed in 
twenty-four hours. He is to be kept in bed with a rubber 
sheet under him, and to be saturated, as it were, in crude 
linseed oil. If the oil is not used abundantly, it is worse 
than useless. This plan of treatment worked admirably in 
one of my cases. Thyroid extract has proved helpful in 
some cases. In one of mine it aggravated the disease, and 
the patient made a good recovery after it was stopped, 
and she was treated with vaseline, soda baths, and careful 
feeding. 



136 DISEASES OF THE SKIN. 

Dermatitis Exfoliativa Neonatorum is a disease of new- 
born children, first described by Ritter von Rittershain, 1 and 
said by him to be quite often seen in the foundling asylums 
of Prague. 

Symptoms. It begins at the mouth as an erythema, and 
thence spreads to the trunk and extremities. Then the epi- 
dermis raises itself from the cutis, rumples, and spontane- 
ously exfoliates in large folds, leaving a dry skin, or there 
may be exudation under the epidermis. It lasts seven to 
eight days, and begins usually between the second and fifth 
week of life. Relapses may occur. There is no fever, nor 
digestive disturbances. Furuncles, abscesses, or phlegmonous 
infiltration, with gangrenous destruction, may follow. Re- 
covery takes place in about half the cases. It is supposed 
to be a pysemic condition of the skin. 

Treatment. Alkaline lotions will prove beneficial in the 
early stage. Later, a protecting ointment, such as that of 
oxide of zinc, or simple vaseline, followed by cornstarch, 
will be indicated. 

Dermatite Exfoliative Aigue Benigne. See Erythema 
scarlatiniforme. 

Dermatitis Gangrenosa or Sphaceloderma Gangrene 
of the skin may be due to a great variety of causes. Many 
cases are due to purely local causes, such as burns, bruises, 
compression, chemical action, and the like. It is seen in 
the course of diabetes, albuminuria, and some cardiac dis- 
eases ; with degenerative changes taking place in the vascu- 
lar walls of arteries, or plugging of their lumen ; and in con- 
nection with other skin diseases, as carbuncle. Besides 
these we have a group of little-understood cases of gan- 
grene, due, apparently, to nervous influences, and occurring 
in connection with diseases of the nervous system. These 
may occur anywhere, and may be superficial or deep. They 
behave like surgical gangrene, and are to be treated on the 
same principles. It is always to be borne in mind that 
gangrene occurring in hysterical women is apt to be self- 

1 Archiv f. Kinderheilkunde, 1880, i. 53. 



DERMATITIS GANGRENOSA. 137 

imposed. If such cases are carefully noted, it will be 
observed that the spots appear where they can be most 
readily reached by the patient's right hand, or left, if she 
be left-handed. A case of that sort was recently seen by me, 
which rapidly became well as soon as I told the girl that 
she knew the cause of the trouble as well as I did, and need 
have no more of it unless she wished. 

Treatment. In all these forms of gangrene attention 
must be given to the general health of the patient, and the 
lesions must be treated on general antiseptic principles. 

There are two forms of cutaneous gangrene that have re- 
ceived special names that must be noticed here. They are: 
1. Symmetrical gangrene or Raynaud's disease ; and, 2. 
Dermatitis gangrenosa infantum. 

1. Symmetrical Gangrene. This was first described by 
Maurice Raynaud, 1 and since then has been observed by 
others, although it is a very rare disease. It most often 
attacks the second and third phalanges of the fingers and 
toes ; next most frequently the nose and ears ; but any part 
may be attacked. The parts become pale and hard, and then 
swell. They feel numb, but the patient may experience 
darting or stabbing pains in them. If pricked, no blood 
escapes. The process may stop here and the parts may re- 
turn to their normal state ; or, after a time, hours or weeks, 
they become black, a line of demarcation forms, and separa- 
tion of the affected skin takes place. The process may stop 
short of the complete destruction of the part, and recovery 
may take place, though relapses are liable to occur. The 
disease is symmetrical. It may involve all four extremities, 
but usually only two are affected. Bullae may form. The 
nails may fall. 

Etiology. Men are more often affected than women. 
People of all ages are liable to it. Exposure to cold seems 
to be a causative factor, and not a few of its victims have 
been subject to chilblains or other symptoms of poor circu- 
lation. The malarial cachexia and the gouty habit have 
been supposed to be predisposing causes. It is probably of 
neurotic origin. 

1 These de Paris, 1862. 



138 DISEASES OF THE SKIN. 

Treatment. The internal treatment that has done best 
has been the administration of quinine and belladonna. 
Locally, galvanism may be tried, as it has done good. 
Cold applications are said to be better than hot. If 
gangrene has occurred, it must be treated on surgical 
principles. 

Prognosis. The outlook is not good. Death may re- 
sult in those who are not robust. Even if one attack is 
recovered from, another is apt to occur. 

2. Dermatitis G-angrcenosa Infantum (Crocker). Syno- 
nyms : Varicella gangrenosa (Hutchinson) ; Pemphigus 
gangrsenosus (Stokes); Rupia escharotica (Fagge); Ecthyma 
infantile gangr6neux (Pineau) ; Gangrenes multiples ca- 
chectiques de la peau; Ecthyma ter6brant de Tenfance 
(Baudouin) . 

Under these names has been described a disease of the 
skin that occurs most often after varicella, but may occur 
after other diseases of the skin in children. It consists 
essentially in the formation of deep or superficial round or 
oval ulcerations beneath a black slough, and following upon 
a varicella or other pustule. The lesion when fully formed 
may be one inch or more in diameter, and three-quarters of 
an inch deep. The wider the slough, the deeper is the 
ulcer. Around the slough is a red areola. Crocker says 
that if the gangrene occurs while the varicella is still pres- 
ent, it begins on the head or upper part of the body, and 
then looks like a vaccination pustule ; while if it begins late 
in the course of the disease, the lesions will be located on 
the lower half of the body, especially the buttocks and 
thighs. In the latter cases the affected parts are riddled 
with ulcers of all sizes, shapes, and depths. If several 
ulcers run together, very large and irregular ones may 
form. If the lesions are extensive or numerous, they may 
cause death very frequently by pulmonary complications. 

Etiology. Infants and young children under three years 
of age are those affected by this disease, and most of them 
are girls. Debilitating diseases, such as congenital syphilis, 
tuberculosis, and scrofula so called, predispose to the dis- 
ease. In my service at the Infants' Hospital on Randall's 



DERMATITIS HERPETIFORMIS. 139 

Island cases of this sort were not infrequent. In an epi- 
demic of varicella, occurring in 1890, two cases were met 
with, one quite extensive upon the upper part of the back. 
The children received in the institution are from the lowest 
dregs of our population, and the disease seems to be a 
product of several dyscrasic conditions plus a possible mi- 
crobic infection. 

Treatment. The cases are to be managed upon general 
principles. Tonics, fresh air, good food, and hygienic sur- 
roundings, and remedies addressed as far as may be to the 
underlying constitutional condition are the best means for 
combating the disease. Crocker recommends quinine and 
sulpho-carbolate of soda, five grains every three hours. 
Locally, the Randall's Island cases were treated with iodo- 
form and antiseptic dressings. Aristol would probably 
answer well. 

Prognosis. The prognosis is not good in bad cases. 
Death is apt to result from lung complications, or pyaemic 
infection. 

Dermatitis Herpetiformis. This name was first suggested 
by Duhring, 1 of Philadelphia, for a composite disease which 
is characterized by great multiformity, and marked grouping 
of the lesions ; by pruritus of varying intensity ; by chron- 
icity of course ; and by a strong tendency to relapse. Under 
it he includes the herpes impetiginiformis of Hebra, the hy- 
droa of Bazin and Tilbury Fox, the herpes phlyctsenodes of 
Gibert, the herpes gestationis of Bulkley, pemphigus pruri- 
ginosus and circinatus, pemphigus a petites bulle, hydroa 
bulleux, and the herpes circinatus of Wilson. Though the 
name has been adopted by many, the exact status of the 
disease has not been settled. The account of the disease 
given here is based upon Duhring's writings, space not 
allowing of a discussion of the subject. 

Symptoms. In severe cases there may be prodromata 
for several days preceding the outbreak, such as malaise, 
constipation, fever, chills, sensations of heat or cold, or these 
alternating, and itching. In mild cases these are absent. 

1 Journ. Amer. Med. Assoc, 1884, iii. 225. 



140 DISEASES OF THE SKIN. 

The onset of the disease may be gradual or sudden — the 
latter not infrequently. The eruption may be diffused over 
the greater part of the general surface, or it may be in local- 
ized patches. Itching and burning, which are severe, precede 
or accompany the outbreak. It may begin as an erythe- 
matous, vesicular, bullous, pustular, or papular eruption, or 
by a combination of two or more of these, the multiformity 
being a characteristic. It shows a tendency for one variety 
of lesions to pass over into another, either during the attack 
or at some relapse. The relapses occur at intervals of 
weeks or months. All regions are invaded, the course is 
essentially chronic, and in pronounced old cases the skin is 
excoriated and pigmented. The mucous membranes may be 
involved. 

Dermatitis herpetiformis erythematosa. This form is 
usually of urticarial or erythema-multiforme type, and oc- 
curs either in patches or diffused. The circumscribed 
patches may coalesce and form larger patches with mar- 
ginate outline. The color varies with the age of the lesion, 
becoming darker with age. There may be maculo-papules, 
flat infiltrations, or vesico-papules. It may continue in this 
way for days or weeks, but usually it changes to the multi- 
form type. There is pruritus. 

Dermatitis herpetiformis vesiculosa. This is the form 
most usually met with. The vesicles are from pin-head to 
pea-sized, flat or raised, irregular or stellate in shape, glis- 
tening, pale-yellow or pearly, firm, tensely distended, and 
without areola. There may be papules, papulo-vesicles, 
vesico-pustules, and sometimes bullae. The lesions are dis- 
seminated, but aggregated into clusters of two, three, or 
more, or may form groups as large as a silver dollar. If 
the vesicles are near together, they tend to run together 
and form blebs, which are raised and surrounded by a pale 
or distinct red areola, and of a puckered or drawn-up ap- 
pearance. The eruption is usually profuse. All regions 
are affected. Severe itching and sometimes burning last 
until the vesicles are broken, which may not be for several 
days. Sometimes there is a good deal of constitutional dis- 
turbance. This is Fox's hydroa herpetiforme. 



DERMATITIS HERPETIFORMIS. 



141 



Dermatitis herpetiformis bullosa. In this form we have 
more or less typical bullae filled with cloudy or serous fluid, 
from pea- to cherry-sized, irregular or angular in outline, 



Fig. 17. 




Hand of a person affected with dermatitis herpetiformis. (From a replica of 
Baretta's model, No. 1333, in the Museum of the St. Louis Hospital, Paris.) 

and with or without an inflammatory base. They occur in 
groups, with red and puckered skin between, and more or less 
vesicles and pustules disseminated over the skin. All parts 
of the body are affected. They come out in crops at 

7* 



142 DISEASES OF THE SKIN. 

intervals, rupture in two or three days, and crust over. 
This is Fox's hydroa bulleux. 

Dermatitis herpetiformis pustulosa. This form is less 
clearly defined than the vesicular form, because vesicles, 
vesico-pustules, and bullae often occur at the same time. 
The pustules are acuminated, round or flat, tense or flaccid, 
and vary in size from a pin-point to a twenty-five-cent 
piece. The large pustules generally have an areola. They 
tend to flatten, spread, and dry in the centre, and to group. 
On the trunk we may find a central pustule surrounded by 
a variable number of small pustules. They are opaque, and 
whitish or yellowish. There may be slight hemorrhagic 
exudation into them. They are slow of development, an 
attack lasting from two to four weeks. There is more 
marked constitutional disturbance than in the other forms. 
It is accompanied by heat, pricking, and itching. It some- 
times precedes, follows, or alternates with the other forms. 

Dermatitis herpetiformis papulosa. This is the rarest 
variety of all, and consists in small or large, irregularly 
shaped, firm, reddish, or violaceous papules in disseminated 
groups, the papules being usually excoriated on account of 
the scratching to relieve the severe itching. Ill-defined 
papulo-vesicles are also present. 

Dermatitis herpetiformis multiforme is simply a combina- 
tion of all the former varieties, with the type changing from 
time to time. Pigmentation is a feature of this variety as 
well as in all the others, after the disease has lasted for 
some years. 

Etiology. The disease occurs in both sexes, and is sup- 
posed to be a tropho-neurosis. Little is known as to its 
causes. It occurs quite independently of pregnancy, and in 
one case became better during the same. Another case was 
aggravated during pregnancy, and by irregular menstrua- 
tion. One case seemed to arise from a nervous shock, and 
many cases are seen in the subjects of nervous exhaustion 
of various kinds. By Bazin the gouty diathesis was con- 
sidered to be a predisposing cause of hydroa, and hence 
possibly of dermatitis herpetiformis. Winfield has re- 
ported four cases in which sugar was found in the urine. 



DERMATITIS HERPETIFORMIS. 143 

It is probable that future investigations will throw some 
light on the origin of this disease. 

Diagnosis. The disease must be differentiated from 
erythema multiforme, eczema, and pemphigus. It differs 
from erythema multiforme by not occurring markedly upon 
the backs of the hands, wrists, forearms, and feet; by its 
more intense itching, instead of the burning of erythema ; 
by its chronicity and greater tendency to relapse ; and by 
its obstinacy to treatment. If the case is watched for a 
time, the character of the eruption will be seen to change. 

The vesicular form of dermatitis herpetiformis differs 
from vesicular eczema in having larger vesicles of angular 
or stellate outline, and with no disposition to rupture ; in 
the grouping of these vesicles in small clusters ; in its her- 
petic character ; more intense itching ; greater constitu- 
tional disturbance ; and greater obstinacy to treatment. 

The papular form differs from papular eczema in the 
irregularity of the size and form of the papules ; their strong 
disposition to group ; their slow evolution ; their appear- 
ance in crops with free intervals ; the chronicity of its 
course ; and obstinacy to treatment. 

It differs from herpes iris by being a general eruption, 
and by not having the groups of vesicles arranged in circles 
about a central vesicle. 

It differs from pemphigus by the grouping of its lesions, 
by their more inflammatory, herpetic aspect, and by the 
occurrence of vesicles and pustules at the same time with 
the bullae. If only bullae are present, the diagnosis is 
difficult. 

Impetigo herpetiformis is always and only pustular, and 
never has erythematous patches, vesicles, or bullae. It de- 
velops by new lesions springing up in a circular manner 
about the old ones. It is unattended by pruritus, and is a 
grave disease, often ending fatally. 

A well-marked case of dermatitis herpetiformis with ery- 
thematous patches, grouped vesicles, pustules, and bullae of 
stellate form, intensely pruritic and with a myriad of excor- 
iations, is so characteristic as to admit of no doubt in diag- 
nosis. 



144 DISEASES OF THE SKIN. 

Pathology. But little has yet been done in the study of 
the pathology of dermatitis herpetiformis, but we have a 
careful study of herpetiform hydroa by Elliot, 1 which is 
considered by Duhring as one variety of the disease under 
consideration. He shows that the vesicles originate in the 
epithelium of the sweat ducts, several being implicated at 
the same time, and that the ordinary signs of inflammation 
are present. He believes that the inflammation is second- 
ary, and is seated in the papillary layer of the corium. 
Degenerated nerve fibres are found, and the disease is be- 
lieved to be due to trophic nerve disturbance. 

Treatment. This disease is one of the most rebellious 
to treatment. Hygienic measures, fresh air, proper and re- 
stricted diet, abstinence from all alcoholics, and relief from 
all nervous disturbances must be secured as far as may be. 
Nerve tonics may be given, such as arsenic, strychnine, cod- 
liver oil, hypophosphites, and quinine; alkaline diuretics, 
belladonna in full doses, laxatives, all may be tried. Duh- 
ring 2 places little faith in any of them. Locally Duhring 
has found the best treatment to be sulphur ointment contain- 
ing two drachms of sulphur to the ounce, having it well 
rubbed in with vigorous friction as in scabies. In one 
marked case this treatment gave most satisfactory results in 
my hands. The frictions should be continued for an hour 
at a time. This plan is not suitable for the erythematous 
variety. Other authorities recommend alkaline and bran 
baths, dusting on starch powder with zinc, Lassar's paste, 
resorcin ointment, liquor carbonis detergens in water, 5\j to 
5viij ; calamine lotion, liquor picis alkalinus, tar ointment, 
solutions of carbolic acid, 5j to Sj, dabbed on. All these 
will afford a certain measure of relief, but the disease is apt 
to laugh at our efforts to drive it out. 

Prognosis. The duration of the disease is indefinite. 
Some mild cases may recover in a short time, never to re- 
lapse. The course of the disease is essentially chronic ; it 
may last for many years ; it shows a strong tendency to 

1 N. Y. Med. Journ., 1887, xlv. 449. 

2 Trans. Amer. Derm. Assoc., New York, 1890. 



DERMATITIS MEDICAMENTOSA. 145 

relapse at longer or shorter intervals ; and, as a rule, does not 
materially affect the patient's health. 

Dermatitis, Malignant Papillary. See Paget's Disease 
of the Nipple. 

Dermatitis Medicamentosa. By this is meant inflamma- 
tion of the skin due to the systemic ingestion of drugs. 
There are a great number of drugs that may cause erup- 
tions upon the skin in susceptible individuals. These effects 
are seen but rarely with some drugs, and quite constantly 
with others. The modus operandi of drugs in producing 
eruptions is probably not the same in all cases. Some, 
doubtless, act by irritating the skin while circulating in the 
blood ; some while being excreted by the glandular appa- 
ratus ; while most of them do so by direct or reflex excita- 
tion of the vasomotor nerves. Idiosyncrasy is marked in 
all of them. Erythema is the principal feature of nearly all 
drug eruptions, to which may be added vesiculation or pus- 
tulation. Two drugs, bromine and iodine, produce pustular 
eruptions in nearly all cases where ingested. Most drug 
eruptions appear with more or less suddenness, and disap- 
pear quite promptly when the drug is stopped. They are 
symmetrical and general in distribution as a rule. They 
may be universal or localized. The cause of all doubtful 
eruptions of an erythematous type should always be sought 
for in the ingestion of some drug. As a rule, little if any 
treatment is required for this form of dermatitis apart from 
stopping the drug. Sometimes the system becomes accus- 
tomed to a drug, and after a time does not react unfavorably 
to it if its administration is persisted in. With most drugs 
this is not the case. 

The subject of drug eruptions is so large a one that here 
no more than a skeleton account can be given. For fuller 
particulars the reader is referred to Morrow's masterly arti- 
cle in his System of Genito- Urinary Diseases, Syphilology, 
and Dermatology, Volume III., upon which this section is 
founded. 

Acids : Benzoic acid may produce an eruption of urti- 
caria, maculo-papules, or erythema. Boric acid may cause 



146 DISEASES OF THE SKIN. 

an erythematous, psoriatic, or erythemato-bullous eruption. 
The psoriatic form is unique. Carbolic acid causes an ery- 
thema that may be scarlatinous in character. Nitric acid, 
in rare cases, gives rise to a pustular eruption. Salicylic acid 
and salicylate of soda produce erythematous, urticarial, vesic- 
ular, bullous, petechial, or purpuric manifestations. Salol 
has produced urticaria. Tannic acid caused an erythema in 
one case. 

Aconite gives rise to itching, vesicular, pustular, or bul- 
lous lesions. 

Alcohol may cause a generalized erythema and urticaria. 

Amygdala amara causes erythema. 

Antifebrin may give rise to cyanosis. 

Antimony causes an urticarial or vesiculo-pustular erup- 
tion. 

Antipyrin gives rise to an erythema, consisting of small, 
irregularly circular, slightly elevated patches, which may be 
discrete or confluent, and is at times followed by desquama- 
tion. Profuse sweating and itching may accompany it, and 
it affects the chest, abdomen, back, and extremities, specially 
their extensor surfaces. It may be measly in character or 
purpuric. It has also given rise to bullous, furuncular, and 
purpuric eruptions. 

Argenti nitras when used continuously may produce a 
grayish-black discoloration of the skin, or an erythemato- 
papular eruption. 

Arsenic causes erythema of scarlatina type, papules, pete- 
chia, urticaria, vesicles, pustules, herpes zoster, and an ery- 
sipelatous eruption. Itching may attend some of these 
eruptions, and grayish or brownish discolorations of the skin 
have followed prolonged ingestion of the drug. Boils and 
carbuncles have also been produced, as well as thickening of 
the skin of the palms and soles, and that over the knuckles. 

Belladonna produces a scarlatinal eruption with or with- 
out vesicles and pruritus. As the fauces are often reddened 
the resemblance to scarlatina is striking. It will clear up 
in twenty-four hours, and the eruption is patchy, not punctate. 
Moreover, there is none of the prodroma of scarlatina, nor 
the strawberry tongue. The pupils may be dilated. 



DERMATITIS MEDICAMENTOSA. 



147 



Bromine, in combination with potassium, ammonium, and 
other salts, produces the well-known " bromic acne ,J so com- 
monly seen in the treatment of epilepsy. It is an outbreak 




Bromide of potassium eruption in a child. 



of dark-red inflammatory papules, papulo-pustules, and 
cutaneous abscesses that bear a close resemblance to acne, 
and, like it, often leave scars. It differs from acne in hav- 
ing a wider distribution, and in occurring at all ages. This 
is the most common form of bromine eruption, but erythe- 
matous, urticarial, papular, ulcerative, verrucose, vesicular, 
and bullous eruptions have been met with. Rarer forms 
are papillary hypertrophy, resembling condylomata, and 
large, irregular, elevated ulcers. It would be desirable to 
prevent these eruptions, but thus far there is nothing that 
will do so with certainty, except stopping the administration 
of the drug. Arsenic, or sulphide of calcium, or aromatic 
spirits of ammonia may be tried. 

Calx sulphurata gives rise to vesicles, pustules, and fur- 
uncles ; rarely to petechise. 

Cannabis indica caused a vesicular eruption in one case. 



148 DISEASES OF THE SKIN. 

Cantharides and capsicum give rise to erythematous and 
papular lesions. 

Capsicum may cause erythematous and papulo-vesicular 
lesions. 

Chloral produces erythematous, papular, urticarial, vesic- 
ular, and petechial eruptions. At times the chloral ery- 
thema bears a strong resemblance to scarlatina. 

Chloralamide causes a general punctate hyperemia with 
vesicular lesions with febrile reaction. 

Cinchona and quinine produce all the primary lesions of 
the skin, though most frequently an erythema of scarlatina 
type, attended by congestion of the fauces and followed by 
desquamation. 

Conium has an erysipelatous eruption as well as an 
erythematous one. 

Copaiba and cubebs. Their most common eruption is an 
erythema which is often of a scarlatina type, but may resem- 
ble measles, and may be followed by desquamation. Out- 
breaks of urticaria, vesicles, bullae, or petechia may occur. 
Pruritus maybe present. The odor of the drug may usually 
be detected in the breath. 

Digitalis produces an erythema of an erysipelatous, papu- 
lar, or urticarial character. 

Ergot, quite apart from the condition of ergotism, may 
cause vesicles, pustules, furuncles, and petechia. 

Ferrum is said to produce an acne ; also erythematous, 
vesicular, and urticarial eruptions. The iodide of iron is 
the form that usually produces these eruptions. 

Guaiacum and gurjun oil cause eruptions like those of 
copaiba. 

Hydrargyrum gives rise to a scarlatiniform eruption, 
followed by desquamation, as well as urticaria, herpes, 
impetigo, purpura, furuncles, and ulcers. 

Hyoscyamus produces an itching erythematous eruption, 
with more or less oedema and wheals. Purpura has also 
followed its use. 

Iodine and its compounds, like bromine, give rise to a 
pustular or papulo-pustular, acneiform eruption, usually 
upon the face, back, and upper part of the chest and arms ; 



DERMATITIS MEDIC AMEN 108 A. 149 

but often general. This is the most typical form of erup- 
tion, but an erythema limited to the face and chest, or 
general, an urticaria, a vesicular erythema, or an eczema- 
like eruption, a bullous form resembling pemphigus, as well 
as carbuncular, petechial, and nodular eruptions, may 
occur. Sometimes there will be more than one type present. 
It is supposed that iodic eruptions occur more often in cases 
in which the kidneys are more or less inactive. They 
sometimes follow the administration of very small doses. It 
is thought that the iodide of sodium is less apt to cause cuta- 
neous disturbances than are the other salts of iodine. At 
times the system becomes accustomed to the drug, or the 
kidneys acting more freely relieve the skin. The trouble 
may be relieved or, to a large extent, obviated by adminis- 
tering the salt largely diluted in vichy or seltzer water, or 
giving it in milk. The free use of alkaline diuretics will 
relieve the skin. Arsenic has also been commended, but 
does no better here than in the bromine eruptions. 

Ipecac in one case caused burning heat, with an erysipe- 
latous eruption. 

Nux vomica and strychnine have given rise to a scarla- 
tina-like erythema and a miliary eruption. 

Oleum morrhuse may cause an eczematous eruption or an 
acne. Oleum ricini may cause an itching erythema. Oleum 
santali may cause a general petechial eruption. 

Opium causes itching and an erythema resembling scar- 
latina or measles in character, which, though often widely 
distributed, is not infrequently limited to certain regions. 

Morphine may cause urticaria, ulcers, a papular, vesicu- 
lar, or pustular eruption. 

Phenacetin may cause a general erythematous eruption. 

Phosphorus causes bullous eruptions, and also purpura. 

Pix liquida produces an erythema. 

Potassii chloras has caused a papular erythema, while 
bluish spots on the skin and a general cyanosis may occur 
after continuous use of the drug. 

Quinine produces a scarlatiniform erythema, as well as 
urticarial, purpuric, vesicular, and bullous eruptions. 

Rhubarb may cause a scarlatiniform erythema. 



150 



DISEASES OP THE SKIN. 



Santoninum produces an urticaria or a vesicular eruption. 

Stramonium gives rise to an itching or burning scarlati- 
noid erythema, a petechial eruption, or an erysipelatoid 
inflammation. 

Strichnine may cause a scarlatiniform rash. 

Sulphonal produces a scarlatiniform erythema. 

Sulphur causes dark discoloration of the skin, and an 
eczematous, pustular, furuncular, or papular exanthem. 

Tuberculin may cause scarlatiniform or measles-like 
patches of erythema, as well as a psoriasiform eruption. 

Tansy has caused a varioliform eruption. 

Turpentine and terebene may cause scarlatiniform ery- 
thema and a papular and vesicular eruption. 

Veratria gives rise to an erythematous eruption. 

Treatment. The treatment of all drug eruptions is the 
same, namely, stopping the use of the drug and giving 
alkaline diuretics. Locally soothing remedies should be 
applied, such as cold cream, vaseline, and oxide of zinc 
ointment. 

Dermatitis Papillaris Capillitii. Synonyms : Dermatitis 
papillomatosa capillitii ; Framboesia ; Sycosis frambcesia 

Fig. 19. 




(Hebra) ; Sycosis capillitii (Rayer) ; Mycosis frambcesiodes, 
or Acne keloidique, or Pian rubo'ide (Alibert) ; Acne 
keloid. 



DERMA TITIS REPENS. 151 

Symptoms. — This is one of the rare diseases of the skin. 
It begins as an eruption of small-sized papules upon the back 
of the neck at the margin of the hair. They are of the color 
of the skin, or slightly red with an inflammatory halo ; ex- 
ceedingly hard and firm ; and when pricked they give vent 
to a little bloody serous fluid. Increasing slowly in num- 
ber and crowding together, they form raspberry-like eleva- 
tions with uneven lobulated surfaces. Gradually the 
disease spreads laterally and also upward upon the hairy 
scalp, even reaching the vertex after months and years. 
After a time the masses may soften a little and contain pus. 
At times they secrete a foul-smelling fluid, and crust. 
Gradually they become sclerosed and keloidal. Pustules 
may form on the hairy scalp, and little tufts of hair protrude 
out of them. When they become keloidal they may be bald 
or tufted with hair. Hairs plucked from the growths are 
sometimes normal, and sometimes atrophied. There may 
be pain or tenderness, or there may be no subjective symp- 
toms. 

Etiology. Both men and women are affected, and the 
disease may begin at any age. The etiology is obscure. It 
has been suggested that it may be due to the rubbing of the 
shirt collar. 

Diagnosis. If the characteristics of the disease are re- 
membered, there should be no difficulty in diagnosis. In 
sycosis we have no hard tumors, and the single hairs are 
surrounded by pustules. Warts are not so hard, do not 
tend to increase in size, and do not become keloidal. 

Treatment. The best treatment is to scrape away the 
small lesions with the curette and excise the larger ones. 
After either operation the base must be cauterized. They 
may be removed with the galvano-cautery. 

Prognosis. So far as reported the growths are benign, 
and have no effect upon the health of the patient. They 
are progressive and show no tendency to spontaneous re- 
covery. They are obstinate to treatment and prone to 
relapse. 

Dermatitis Repens. Crocker describes this as a spread- 
ing dermatitis, usually following injuries, and probably 



152 DISEASES OF THE SKIN. 

neuritic, commencing almost exclusively on the upper ex- 
tremities. It begins about some slight injury and spreads 
over the affected limb with a well-defined, undermined ad- 
vancing edge. The eruption suggests eczema rubrum, but 
its sharply defined, undermined spreading edge distinguishes 
it from it. It runs a chronic course and is obstinate to treat- 
ment. It yields best to antiseptics such as lactate of lead, 
permanganate of potash, and salicylic acid. 

Dermatitis Traumatica. This term is used to comprise 
all inflammations of the skin that are due to traumatic in- 
fluences, such as blows, rubbing and the like. It presents 
the usual signs of inflammation to a greater or less extent, 
according to the degree of traumatism and the susceptibility 
of the individual skin. The irritation of the skin, due to 
scratching, is a common instance of this form of dermatitis. 
Under certain circumstances it easily develops into an 
eczema. The chafing of the skin met with in horseback- 
riding, in those unaccustomed to the exercise, is another 
common instance. 

Treatment. The treatment of this form of dermatitis 
should be soothing, such as by the free use of dusting-pow- 
ders, alkaline lotions, or mild ointments, such as that of the 
oxide of zinc. Unna 1 recommends for the prevention of 
the dermatitis due to horseback-riding, that the part should 
be smeared over with a weak resorcin or ichthyol ointment. 

Dermatitis Venenata. Redness, swelling, and heat, fol- 
lowed or attended by the formation of a vast number of small, 
closely crowded together vesicles that may remain isolated 
or run together and form bullae, are the symptoms that con- 
stitute this form of dermatitis, the cause of which is always 
some sort of irritant applied to the skin. The irritant is 
usually of a chemical nature, and quite commonly is derived 
from plants. 

Rhus-poisoning. The most frequent cause of dermatitis 
venenata is contact of the susceptible skin with the leaves of 
the rhus toxicodendron, the poison-ivy, and the rhus ven- 
enata, the poison-sumach, and the rhus diversiloba, the 

1 Monatshefte f. prakt. Dermat., 1888. No. 21. 



DERMATITIS VENENATA, 



153 



poison-oak. Dr. James C. White, 1 of Boston, has written 
a most complete and learned work on the subject, and it is 
to this that the reader is referred for a more detailed account 
of the disease than can be here given. The mildest degree 
of irritation is an erythema. Commonly the reaction is 



Fig. 20. 




Dermatitis venenata from poison-ivy. 2 

more marked. The patient first experiences a little burning 
or itching, and attention being drawn to the part it is found 
to be reddened and swollen. In some cases we may have 
wheals. In a few hours papules, and then vesicles, will 



1 Dermatitis Venenata, Boston, 1887. 

2 From a photograph by Dr. H. W. Blanc, of New Orleans. 



154 DISEASES OF THE SKIN. 

form, and perhaps bullae. The swelling may be intense, so 
as, on the face, completely to close the eyes. I have seen it 
so great on the scrotum as to give the appearance of an im- 
mense hydrocele. The vesicles may be present in a count- 
less multitude. The acute developing symptoms may last 
several days, and then gradually subside. The vesicle con- 
tents either dry up or discharge upon the skin. The parts 
crust, the swelling and redness slowly disappear, and the 
skin once more becomes normal. When the dermatitis is 
due to the poison-ivy the cause of the trouble is supposed 
to be toxicodendric acid. The parts most usually affected 
are the hands and face in both sexes, the penis in the male 
and the breast in the female ; that is, those parts that come 
in direct contact with the poison, or to which it is most lia- 
ble to be conveyed by the hands. In some rare cases, and 
in extremely sensitive individuals, the whole body may be 
affected, and there may be grave constitutional disturbances. 
These bad cases are met with in children whose legs are un- 
covered. Most persons, perhaps, are not susceptible to the 
poison. Some few are so susceptible that even having the 
wind blow on them from over one of the plants will set up 
the dermatitis. 

It is probably not true that the dermatitis will relapse 
after an interval of time, but it has been observed that an 
eczema may follow the dermatitis, and that this may show a 
certain amount of periodicity in its outbreaks. White says 
that while the poison may be most active in the flowering 
season, it is sufficiently active at all seasons, and that the 
poison resides not only in the leaves but also in the wood, 
bark, and fruit. The disease is not contagious after the 
parts have been well washed. 

Diagnosis. The eruption differs from that of eczema by 
seeking the inner sides of the fingers, the hands, face, 
breasts, and genitals ; by the greater amount of swelling 
that commonly attends it ; by the vast number of crowded 
together, u lurid" vesicles; and by the occasional occur- 
rence of the eruption in its early stage in streaks, sugges- 
tive of striking against the plant. A history of having been 
in the country will sometimes be an aid in diagnosis. 



DERMATITIS VENENATA. 155 

Treatment. The disease is a self-limited one. It is, 
therefore, natural that there are many i( sure cures " for it, 
and nearly every section of the country has some popular 
remedy. Lime-water, that can be procured anywhere, will 
afford relief as promptly as anything. The parts are to be 
kept constantly covered with lint or absorbent cotton con- 
tinuously saturated with it, or with a saturated solution of 
bicarbonate of soda. At night we cannot use this if the 
patient sleeps, as the cotton or the lint dries. So it is better 
at this time to use some simple ointment, as cold cream, 
oxide of zinc, or diachylon diluted one-half. This treatment 
commends itself on account of its efficacy, cheapness, safety, 
and accessibility. White recommends black wash (calomel, 
5j ; aq. calcis, Oj), applied for half an hour at a time, two 
or three times a day. He cautions against the danger of 
using it in extensive cases. As a substitute for it he gives : 



J& . Zinci oxid. , 
Ac. carbol., 
Aq. calcis, 



5iv; 


16 


3j; 


4 


Oj; 


500 



M. 



Sugar of lead in solution is a well-known remedy, and 
efficacious, but dangerous. Morrow 1 recommends : 



&. Sodii hyposulphitis, 


Ij; 


25 


Glycerini, 


3ss;_ 


12 


Aquse, 


ad ^viij ; 


200 


S. Kept constantly applied. 







M. 



After the acute stage has passed the case should be treated 
like an eczema. If the constitutional disturbance is marked, 
the patient should be cared for upon general medical prin- 
ciples. 

While the poison-oak, or ivy, causes the symptoms most 
often spoken of as dermatitis venenata, there are a number 
of other plants that will produce like, if not as severe, symp- 
toms. Of the commoner ones we find the oleander, Jack-in- 
pulpit, skunk cabbage, bitter orange, May-apple, arnica, 
burdock, golden rod, and common daisy. But space will 

1 Journ. Cutan. and Ven. Dis., June, 1886. 



156 DISEASES OF THE SKIN. 

not allow of a complete list of these. Goa powder and its 
derivative, chrysarobin, produce a marked dermatitis in ad- 
dition to their mahogany-staining of the skin. The action 
of croton oil, mustard, stinging-nettle, and oil of turpentine 
is well known. Tar may excite a general dermatitis or an 
acne-like inflammation of the follicles called " tar acne," the 
follicles of the skin being stopped up and their mouths filled 
with a black plug of tar. A somewhat similar eruption is 
seen in workers in flax and paraffin. Workers in picking 
and packing peaches have an eczematous dermatitis de- 
veloped upon the wrists, forearm, neck, and upper part of 
the chest. 

A great number of chemicals produce dermatitis of vary- 
ing degree. Pyrogallic acid produces burning and inflam- 
mation, and covers the part with a black coating on account 
of its oxidation. Not only does it destroy diseased tissues, 
but it may cause sloughing of the sound skin. Chloroform 
will blister if prevented from evaporation. This peculiarity 
is sometimes employed for vesication. The strong acids 
destroy the skin, as also arsenic. Sulphur, iodine, iodo- 
form, creolin, mercurial preparations, chloride of zinc, 
bichromate of potash, and caustic potash cause varying 
degrees of dermatitis. Electricity will redden and inflame 
the skin, and not a few cases of dermatitis have resulted 
from wearing clothing dyed with aniline dyes. 

Dermatolysis (Du 5 rm-a 2 t-o 2 l / i 2 -si 2 s). Synonyms : Cha- 
lastodermia ; Cutis pendula ; Pachydermatocele. 

This term is applied to two entirely different diseases of 
the skin. In one we have folds of loose thickened skin and 
subcutaneous tissue that sometimes form huge masses hang- 
ing down from the side of the face, trunk, or any part of 
the body. The skin is soft, and does not appear altered, 
excepting that it is pigmented to a certain extent. This 
form is really a species of fibroma. True dermatolysis is a 
yet more rare affection, in which, owing to some defect in 
the attachments of the skin, it can be pulled away from the 
body like the skin of a cat. The " Elastic-skin Man" is an 
instance of this. There have been several of these freaks. 
The one mentioned could pull the skin from his chest up to 



DISTICHIASIS. 157 

his eyes. The condition is congenital, but can be increased 
by cultivation. 

Treatment. The treatment of the first variety is by 
excision before it becomes too large. 

Dermatomycosis. A disease of the skin due to a vege- 
table parasite. 

Dermatosclerosis. See Scleroderma. 

Dermatosis Kaposi. See Atrophoderma pigmentosum. 

Dermographia. See Urticaria factitia. 

Desmoides. See Fibroma. 

Desquamative Scarlatiniform Erythema. See Derma- 
titis exfoliativa. 

Diabetic Eruptions. According to Brocq, they may be 
divided into two great classes : 1. Those in direct relation to 
alterations in the general economy, such as pruritus, chronic 
papular urticaria, acne cachecticorum, erythema, lichen, ec- 
zema, herpes, ecthyma, furuncle, carbuncle, xanthelasma, 
gangrene. 2. Dermatoses due directly to the contact of the 
secretions of the body charged with sugar, and more espe- 
cially the eczema of the genitals, caused by contact with the 
urine. 

Kaposi 1 has described a bullo-serpiginous gangrene of 
diabetics, which begins by a disseminated eruption of bullae 
upon the extremities. The bullae dry up in the centre into 
a black crust, while at the periphery there is a ring of fluid 
pushing up the epidermis. When the crust is removed 
sphacelated skin is exposed, which separates and leaves a 
red, granulating surface. The penis is a favorite site for 
this form of gangrene. It must be treated on general sur- 
gical principles. 

Distichiasis (Di 2 s-ti 2 k-i-a'si 2 s). This is a congenital or 
acquired condition of the cilia, in which they grow in two 
distinct rows, the inner row being directed inward so as to 
scrape the cornea. According to Michel, generally the 
outer third of the upper lid is affected alone, the deformity 

1 Wien. med. Presse, 1883. 



158 DISEASES OF THE SKIN. 

is symmetrical and bilateral, and of embryonic origin. 
Electrolysis offers the best method of relief. These cases 
belong to the ophthalmic surgeon. 

Dracontiasis. See Guinea-worm disease. 

Durillon. See Callositas. 

Dysidrosis. See Pompholyx. 

Ecchymomata and Ecchymoses. See Purpura. 

Ecdermoptosis (Huguier). See Molluscum epitheliale. 

Ecthyma (E^-thi'ma 3 ). Synonyms : Furunculi atonici ; 
Phlyzacia agria ; (Ger.) Eiterpusteln ; (Fr.) Furoncles 
atoniques ; (Ital.) Rogna grossa. 

A cutaneous eruption of deep-seated pustules, with hard, 
elevated, reddened bases, attended by the formation of thick, 
greenish, or dark-colored crusts, and followed either by 
cicatrices or dark pigmented spots. 

Symptoms. Most if not all cases of so-called ecthyma 
are either pustular eczema, or more probably a contagious 
disease allied to if not identical with impetigo contagiosa. 
As usually described it consists in the outbreak of one or 
more round, flat pustules, whose covers are not fully dis- 
tended, and which have an inflammatory areola. In size 
they vary from a split-pea to a finger-nail, or larger. At first 
they are white or yellow. Subsequently they may or may not 
become reddish from the admixture of blood. They may 
dry up, forming a crust which, on falling, leaves a healthy 
surface. Or they may rupture spontaneously or be broken, 
and form a thick, greenish or blackish crust, under which is a 
raw or superficially ulcerated surface, which on healing 
leaves a pigmented or slightly cicatricial spot. In subjects 
in bad hygienic surroundings quite deep ulcers may result. 
These pustules are usually discrete, but they may group. 
They are both painful and tender. Any part of the body 
may be affected, but they are most often seen on the ex- 
tremities, especially the legs, where the hair is coarse, the 
shoulders, and the back. The course of the disease may be 
acute, each pustule lasting five or ten days, and the whole 
disease lasting about two weeks, but generally it is chronic, 
and kept up by the outbreak of fresh crops. There is more 



ECTHYMA 159 

or less itching. It is both contagious, and auto-inoculable. 
Febrile symptoms may accompany or precede the outbreak 
of the disease, but as a rule they are absent. 

Etiology. Dirt, want, bad hygienic surroundings, the 
strumous diathesis, or a broken-down cachectic condition 
brought on by intemperance or dissipation, all predispose 
to the disease. It is quite often seen in the genus u tramp." 
It follows, not infrequently, upon scratching on account of 
pediculi and scabies. It is most often seen in adults, and 
is rare in children. Like in all other purulent diseases, pus 
cocci are found in the pus, and are the contagious element 
in the disease which is carried from place to place to pro- 
duce new foci of infection. 

Diagnosis. Ecthyma differs from eczema in having much 
larger pustules, which are discrete aod not confluent, in the 
marked areola about the pustules, and in the absence of all 
other signs of eczema. It differs from impetigo contagiosa 
in its pustules being deeper ; in their location upon the ex- 
tremities rather than upon the face and hands ; in not hav- 
ing that flabby, bullous look of a burn of the second degree, 
so common to impetigo ; in having thick greenish or black- 
ish crusts, and not straw-colored stuck-on crusts ; in occur- 
ring in more or less debilitated adults and not in otherwise 
healthy children. But all these alleged differences can be 
readily explained away by the difference of the character of 
the soil on which the contagious principle is implanted. 
Ecthymatous pustules are often seen in connection with 
impetigo contagiosa. From impetigo it differs principally 
in its being a deeper and more inflammatory process, and 
in occurring in debilitated subjects. It resembles the large, 
flat, pustular syphiloderm, but its crusts are not heaped up 
into oyster-shell-like masses, as in syphilis, and when they 
are removed they leave a more superficial, and not so 
punched-out an ulcer. There are more pain and itching 
in ecthyma, and an entire absence of other symptoms or 
history of syphilis. 

Treatment. The first thing to be done in these cases 
is to obtain cleanliness, proper hygienic surroundings, and 
complete abstinence from alcoholics. If there is a general 



160 DISEASES OF THE SKIN. 

debility, tonics must be given and the dietary improved. 
Locally, all crusts must be removed with soap and water, 
the lesions dressed with an ointment containing some anti- 
septic such as — 



]£• Hydrarg. ammon., ^j ; 5 

Ungt. zinci oxidi, ^j ; 100 



M. 



and the part enveloped in a rubber bandage, where such is 
applicable. An ointment or oil containing five or ten grains 
of salicylic acid to the ounce will also answer well. If ulcer- 
ations have formed, they should be treated as will be indicated 
under Ulcers. 

Ecthyma infantile gangreneux. See Dermatitis gangre- 
nosa infantum. 

Ecthyma terebrant de l'enfance. See Dermatitis gan- 
grenosa infantum. 

Eczema (E 2 k r -ze 2 m-a 3 ). Synonyms : (Fr.) Dartre vive, 
ou humide, eczema ; (Ger.) Ekzem, Hitzblatterchen, Flechte, 
nassende Flechte, Salznuss ; Salt rheum, Tetter, Humid 
tetter, Scall, Scald, Heat eruption. 

A non-contagious, inflammatory disease of the skin, 
sometimes acute, more often chronic, attended with itch- 
ing, desquamation or loss of the cuticle, and usually with the 
exudation of serous or sero-purulent fluid either beneath the 
cuticle or upon the denuded surfaces. It may present ery- 
thema, papules, vesicles, or pustules, and its lesions show a de- 
cided disposition to run together and form infiltrated patches. 

Symptoms. This is a most protean disease. It has been 
well said that if a student learns to recognize and treat 
syphilis and eczema, he has possession of the key to the 
whole of dermatology. There are six prominent symptoms 
of the disease: 

1. Redness. 

2. Itching. 

3. Infiltration. 

4. Tendency to moisture. 

5. Crusti ngor scaling. 

6. Cracking of the skin. 



ECZEMA. 161 

In every case there will be four or five of these symptoms ; 
or perhaps all of them. 

Eczema begins suddenly, and most often without any 
constitutional disturbance. Should slight fever and malaise 
be present they are accidental, or an expression of that 
condition of the system that predisposes to the disease, 
and not part of the disease itself. Very often the first 
thing that attracts the patient's attention is itching, and 
when he examines the skin he finds it reddened, and either 
scaly ; or covered with papules, vesicles ; or pustules, or 
moist. 

The tendency of eczema in all forms is to form patches, 
which are infiltrated to a greater or less extent ; ill defined ; 
shade off imperceptibly into the surrounding skin so that 
it is hard to say where they end, with outlying lesions 
about them ; irregular in shape ; of all sizes, sometimes in- 
volving nearly the whole cutaneous surface ; sometimes 
swollen ; and of dark-red color, sometimes with a shade 
of yellow. Beginning by a few lesions the disease in- 
creases more or less rapidly in extent, and it is by 
the running together of the individual lesions that the 
patches are formed. It may clear away after a short time, 
or it may last weeks or months, or become chronic, showing 
little tendency to recovery. There is no constant rule as to 
the course of the disease, though many cases occur and recur 
at certain seasons of the year ; it may be in the summer, 
spring, autumn, or winter. Any or all parts of the skin 
may be affected, but it has a predilection for the flexures of 
the joints, the face, the scalp, and the sulcus behind the 
ear. There may be but a single patch or many of them. 
It commonly affects both sides of the body, but with no 
marked symmetry. 

The subjective symptoms are itching, burning, and a feel- 
ing of heat and tension. Of these the most constant is 
itching, which is present in all cases, and is often so great 
as to cause the patient to excoriate the skin by scratching. 
It is subject to exacerbations and remissions. The latter 
may be complete or incomplete. Burning and tension are 
experienced for the most part only at the beginning of the 



162 DISEASES OF THE SKIN. 

attack or during some exacerbation of a subacute or chronic 
case. 

The old definition of the disease was that it is a vesicular 
one. It is well to disabuse the mind of this impression at 
the start, as there is a form of the disease that is dry 
throughout — the erythematous form. There are five forms 
of eczema, known as the erythematous, papular, vesicular, 
pustular, and squamous. Eczema madidans is but a con- 
venient term to describe a very moist eczema. Eczema 
rimosum or rhagadiforme is but an eczema in which there is 
cracking of the skin, especially about the joints. Unna has 
recently introduced the term eczema seborrhoicum, which, 
though it has not yet taken a secure place in the family, 
has won so much notice that it merits a special description. 

Before discussing each of these forms by itself, it is 
necessary to understand that no one of them, excepting per- 
haps eczema erythematosum, is clear cut and unchanging. 
On the contrary, the disease may begin as a papular ery- 
thema ; upon the papules vesicles may form which will run 
together and soon break down of themselves and form a 
weeping patch ; the subsequent lesions may then be pus- 
tules, and the final stage through which all varieties pass 
before recovery is the squamous. Now we are ready to 
study each variety by itself. 

Eczema erythematosum is most often encountered upon 
the face of an adult, though it may occur elsewhere and in 
children. Beginning as one or more ill-defined red 
patches, it soon forms a continuous patch by the coalescence 
of the smaller ones. Sometimes the whole face is involved, 
sometimes there are several patches. The inflammation is 
often attended by oedema to such an extent that the eyes 
are nearly closed if the disease is in their neighborhood. 
The patient experiences great discomfort on account of the 
burning and stiffness of the skin. The skin feels harsh, 
dry, and thickened ; it is swollen ; its color is bright or 
dull-red ; and there is a slight amount of small adherent 
scales. If it occurs on contiguous folds of skin, there may 
be moisture. Upon the face vesicles may develop, but this 
is exceptional. After lasting for a time the symptoms may 



ECZEMA. 163 

subside, and recovery take place, the patches fading away 
altogether and not in the centre alone. It may assume a 
chronic form and last for years. It is seen at times upon 
the body in the form of very superficial, pale-red, scaly, round, 
circumscribed patches, and constitutes one form of the 
so-called parasitic eczema. 

Eczema papulosum. This is the lichen simplex of the 
old writers. It consists in an eruption of pin-point to 
pin-head, bright or dull-red, acuminate, discrete, grouped, 
or perhaps confluent papules. Very frequently the papules 
are capped by vesicles. The papules may remain discrete 
throughout their course with an occasional small confluent 
patch to betray the nature of the disease. This is one of the 
most itchy varieties of this pruriginous disease, and the 
scratching consequent upon it produces excoriations, and 
breaking down the vesicles and papules gives exit to the 
serum and converts the patch into a moist one. This 
variety is located preferably on the extensor aspects of the 
limbs. The life of the individual papule is comparatively 
long — days or weeks. It is often obstinate to treatment. 

Eczema vesiculosum is the most common and most char- 
acteristic form, and consists in an eruption of pin-point to 
pin-head, rounded or acuminate vesicles that appear upon 
a reddened surface in immense numbers. Prickling and 
tingling precede the outbreak ; intense itching, and more 
or less swelling attend it. The vesicles group, and perhaps 
coalesce, and soon rupture of themselves, and discharge a 
clear, sticky, mucilaginous fluid that possesses the quality 
of stiffening and staining linen, and dries into a light-yellow 
crust. The vesicles rupture so early that it is rare for the 
physician to see a case with the vesicles intact. New vesi- 
cles form about the patch, and break down ; the discharge 
continues from the sites of the vesicles, and the crust con- 
tinuously forms. A raw surface is exposed when the crusts 
are removed. Sometimes when the crust is prevented from 
forming on account of friction, there is a weeping surface 
which has been called eczema madidans or rubrum. Event- 
ually the discharge ceases, the hyperemia lessens, scaling 
takes place, and after a time the skin returns to its normal 



164 DISEASES OF THE SKIN. 

condition. This form of eczema seeks the soft parts of the 
skin, the flexures of the joints, the flexor surfaces of the 
limbs, and behind the ears. It may involve the whole or 
nearly the whole cutaneous surface. After it has lasted a 
little while in a part the skin is evidently thickened. With 
it papules and pustules very generally are found. 

JZczema pustulosum. Under this head many authors, 
notably the Vienna school, place all cases of impetigo. 
Like the pustular syphilide, this form of eczema occurs in 
more or less broken down, cachectic, delicate, or strumous 
subjects. It is the most common form of eczema met with 
in children, and in them occurs by preference on the face 
and head. The eruption consists of small pustules that may 
start as pustules or develop from vesicles. They are pre- 
sent in large numbers, and tend to break down and form 
patches covered with greenish crusts. If blood is drawn by 
scratching, the crust will be blackish. They are somewhat 
larger than the characteristic vesicles, and have a fondness 
for hairy parts, though any part of the body may be 
affected. This and the previous form often merge into each 
other. It is not so itchv as the other forms. It may change 
into an eczema madidans, and it passes through the 
squamous stage on the way to recovery. 

Eczema squamosum is the final stage through which most 
cases pass on their way to recovery. In it the skin is dry, 
red, and covered with thin, papery, flat, large or small 
scales. It is a condition of the skin in which the formation 
of its corneous layer falls short of perfection. The disease 
may continue in this condition for an indefinite time, a 
chronic eczema, with occasional exacerbations. Then it 
may pass away entirely and the skin become quite well ; or 
some local injury may cause an acute outbreak of eczema. 
The skin in this form is more or less thickened, and deep 
cracks are liable to form about the joints, because the infil- 
tration of the skin interferes with its elasticity, and it breaks 
instead of stretching when the joint is extended. While 
the patches are usually ill defined, in some cases they will 
be round, and with well-marked borders. This form is 
spoken of as orbicular eczema. 



ECZEMA. 165 

Eczema may be acute or chronic — terms that apply not 
to the length of time that the disease has lasted, but to the 
symptoms it presents. It predisposes to ulceration upon 
the legs when combined with varicose veins, and then is 
named eczema varicosum. This must not be confounded 
with a somewhat similarly sounding name, eczema verru- 
cosum, which is a rare form, in which the skin takes on 
a warty appearance on account of a hypertrophy of the 
papillae. 

Etiology. Like its symptoms, its causes are numerous. 
It may arise from purely local causes, but even then it is 
probable that we should assume, in most cases, a predispo- 
sition on the part of the skin. Thus, we have eczemas of 
the hands in washerwomen. Perhaps for a score of years 
they had washed in the same water and with the same soap 
without eczema. Then under the same local conditions, but 
with some unknown internal constitutional state, an eczema 
breaks out. Of external irritants we have the sun, water, 
intense artificial heat, acids, alkalies, traumatism, rubbing 
of opposed surfaces or chafing by the clothing, parasites ; 
in fact, just the same things as will cause a dermatitis, only 
now the action goes further, and a catarrhal condition of 
the skin results. Cold has an undoubted influence on the 
skin, and eczema is more common in winter than in summer, 
and is generally aggravated by extremely low temperature, 
even when the patient keeps in the house. It has been 
observed that children with eczema grow worse when it is 
cold and a high wind is blowing, even though they are not 
exposed directly to these conditions. Vaccination may act 
as a local cause. 

Of the internal or predisposing causes, perhaps the most 
common and active is some digestive or intestinal disturb- 
ance — it may be dyspepsia or malassimilation, or derange- 
ment of the liver, or constipation. At other times the 
kidneys are at fault. Diabetes and Bright' s disease both 
predispose to eczema. Chlorosis and anaemia, uterine dis- 
orders and the menopause, and the strumous diathesis, are 
at times active factors. Derangements of the nervous system 
are exciting causes ; now and again we will meet with cases 

8* 



166 DISEASES OF THE SKIN. 

which appear suddenly after some nervous shock. Rheuma- 
tism and gout and varicose veins are other predisposing 
causes. To most of these internal causes some external cause 
must be added before the eczema appears. 

The French school of dermatology has long held to its 
theory of diathesis, and has taught that the dartrous di- 
athesis is the cause of eczema. Outside of France little is 
known about diathesis. A vulnerability of the skin is 
necessary for the production of an eczema, and many 
patients may fairly be regarded as eczematous, just as others 
may be spoken of as gouty, or rheumatic, or psoriatic. This 
peculiarity or tendency of the skin may be inherited, and 
in so far eczema may be regarded as hereditary. 

The disease attacks all ages, conditions, races, and both 
sexes, and is the dermatosis we are most often called upon 
to treat. It is especially common in children. In Bulk- 
ley's tables, out of 3000 cases, 676 occurred under five 
years of age, and of these 520 were in children under three 
years. Of the remaining cases 1234 were between the ages 
of twenty and fifty, and were divided about equally in each 
decade. About one-third of all skin diseases are eczema. 

These many etiological factors indicate that it is probable 
that our present eczema is a too composite disease, and it is 
for this reason that attempts are constantly made to take 
away certain members of the family and form them into 
separate diseases. Unna and others have asserted of late 
that a parasite, yet undiscovered, is the cause of one variety 
of eczema, his Eczema seborrhoicum. Unna further teaches 
that there are two other varieties of the disease, one due to 
reflex nervous irritation, such as is seen during dentition of 
infants, and one dependent upon the tubercular diathesis. 

Pathology. Eczema is a catarrhal inflammation of the 
skin, analogous to that of the mucous membrane, which has 
its seat principally in the papillary layer of the skin and in 
the rete. This superficial location of the disease is the 
reason why the skin is left unmarked after the disease has 
been recovered from. A tropho-neurosis is supposed by many 
to be the cause of the disease when not due to local irri- 
tants, and Crocker quotes Marcacci as having found 



ECZEMA. 167 

changes in the sympathetic in a fatal case of universal 
eczema. 

Diagnosis. If the six prominent symptoms of eczema 
are remembered, namely, redness, itching, infiltration or 
thickening, exudation or tendency to moisture, crusting or 
scaling, and cracking, they will be of great aid in diagnosis. 
To them should be added the tendency the disease evinces 
to locate in the folds of the joints, between apposed surfaces 
of skin and behind the ears, and the peculiar mucilaginous 
quality of the exudate, which stiffens and stains linen and 
glues the hair together. Fortunately, a diagnosis of eczema 
will fit one out of every three cases. Here will be given 
the general diagnosis, reserving for the sections on regional 
eczema the diagnosis of special forms where necessary. 

Dermatitis is often distinguished with difficulty from 
eczema, and frequently runs over into it. As a rule, it runs 
a more rapid course, its vesicles are longer preserved, bullae 
are apt to form, there is burning rather than itching, and it 
heals readily on removal of the cause. 

Dermatitis exfoliativa is, when, fully developed, a uni- 
versal eruption, while eczema is very rarely so. It is also 
dry, and has abundant large scales, while eczema will ex- 
hibit moisture somewhere, and does not scale so abundantly. 
For further points in diagnosis, see under Dermatitis ex- 
foliativa. 

Erysipelas is attended by fever and marked constitutional 
disturbances, has a sharply defined border, advances steadily 
at its margin, and forms a swollen, deep-red patch upon 
which large vesicles and bullae form. The margin of eczema 
is ill-defined, fading off into the surrounding skin; its vesi- 
cles are pin-point to pin-head size, and there is little or no 
constitutional disturbance. Eczema has a dry, rough sur- 
face in the erythematous form, while erysipelas has at first 
a smooth and shining one. 

Erythema burns rather than itches ; its redness can be 
entirely squeezed out by pressure, leaving a whitish spot, 
and returns promptly when the pressure is removed. In 
eczema pressure will cause the redness to disappear, but it 
will leave a yellow stain in its place. Erythema lacks the 



168 DISEASES OF THE SKIN. 

itching, exudation, scaling or crusting, and cracking of 
eczema, and is prone to appear upon the backs of the hands 
and wrists, and is symmetrical. 

Herpes febrilis resembles eczema only in having vesicles 
upon a red surface. It occurs usually in a single patch 
upon the face ; its vesicles are discrete, and show no ten- 
dency to run together ; its course is short, and it pains or 
burns, but does not itch. 

Zoster occurs in the form of a number of herpetic patches 
following the course of a nerve, and occupying only one 
side of the body — symptoms that are entirely foreign to 
eczema. 

Impetigo contagiosa occurs for the most part upon the 
face, hands, and exposed parts. Its pustules are large, flat, 
and discrete, not small and conglomerate. Its crusts are 
thin and stuck on, not greenish and thick, as in eczema. It 
is a vesico-pustular disease, and often presents large vesicles 
or bullae that look like burns of the second degree. 

Lichen ruber and Pemphigus foliaceus do bear some 
resemblance to eczema erythematosum when generalized. 
But the history of these two is quite different from that of 
eczema. 

Phthiriasis or pediculosis shows parallel scratch-marks 
over the shoulders and excoriations about the waist and on 
the limbs where the seams of the clothing come. If on the 
head, the lesions will be on the occiput, and nits will be 
found on the hair of that region, or of the temples. The 
eruption to which they give rise is an eczema, but the cause 
of it is evident. 

Pruritus cutaneous has no lesions, properly speaking, 
and the excoriations met with are not in patches, but scat- 
tered all over the body at intervals and irregularly. The 
itching is more paroxysmal than it is in eczema, and the 
itching is the only symptom that it has in common with 
eczema. 

Psoriasis, when occurring in typical round, or oval, sharply 
defined patches, with silvery scales, offers no difficulty in 
diagnosis from a typical eczema. From circumscribed 
eczema, that occurs occasionally, it may be diagnosticated 



ECZEMA. 169 

by the color — of a brighter red ; by the scaling, that is 
whiter, thicker, and more laminated, and by finding charac- 
teristic patches either of the one or the other disease else- 
where on the body. When psoriasis occurs in large areas 
it is diagnosticated from squamous eczema by its sharply 
defined border ; its marginate form ; its brighter red ; its 
more abundant, thicker and whiter scales ; its fondness for 
the extensor surfaces of the limbs, while eczema seeks the 
flexor aspects and the flexures of the joints ; its uniform 
character and constant dryness, against the polymorphous 
character of eczema and its moisture ; and its history of fre- 
quent relapses, always of the same sort and always on the 
elbows and knees. 

Rosacea occupies the middle third of the face from above 
downward, attacking the forehead, nose, and chin, while 
eczema affects the whole or part of the face, but never occurs 
on these limited regions alone ; it burns rather than itches ; 
it shows telangiectases, and its redness and occasional dis- 
crete, sluggish, superficial pustules are very different from 
either the dry, harsh, scaly redness of an erythematous 
eczema, or the crusted surface of a pustular eczema. 

Scabies maybe diagnosticated from eczema by its location 
upon the anterior surface of the wrists, between the fingers, 
and upon the abdomen and buttocks of both sexes, and 
upon the nipples and breasts of women, and the penis of 
men. In children the feet are often affected. The pres- 
ence of cuniculi is diagnostic, but they are hard to find in 
some cases. Of course, the eruption in scabies is an eczema ; 
but it is important to recognize, where possible, the cause of 
an eczema in order to cure it. 

Syphilis, like eczema, is a protean disease, but it does not 
itch, and that is an important point in differential diagnosis. 
It is true that occasionally a papular syphilide does itch, but 
the occurrence is so rare that it need not here be taken into 
account. The early syphilides are general eruptions, whether 
macular, papular, or pustular, and the efflorescences never 
form patches, though they may show more or less grouping. 
When the other symptoms of syphilis are present, such as 
the initial lesion, mucous patches, and alopecia, there can 



170 DISEASES OF THE SKIN. 

be no difficulty. It is the later manifestations of the dis- 
ease that offer difficulties in diagnosis, and especially the 
grouped papular lesions that occur on the palms in the form 
of scaly patches. In some cases a diagnosis is impossible. 
The most suggestive symptom of syphilis is the occurrence 
of the disease upon one hand alone. The patch will have 
a wavy outline ; will be scaly, but not moist or crusted ; will 
often show healthy skin in the middle ; and there are apt to 
be isolated, scaly, dark-red papules somewhere in the neigh- 
borhood. The finding of scars of old lesions, or some other 
evidence of syphilis, will aid us. 

Trichophytosis corporis when in disk-shaped patches that 
have not formed rings bears at times so close a resemblance 
to eczema that it is difficult to make a diagnosis at once. 
But in a short time the centre of the disk will clear up and 
the annular ringworm patch will declare itself. Eczema 
does not have annular patches. 

Urticaria, when it has induced itching and has been 
scratched, looks like an eczema. We recognize it by the 
finding of wheals, or the history of them, and by the isolated, 
scattered distribution of the excoriations and papules. Some 
cases of papular urticaria can only be diagnosticated after 
prolonged observation. 

Treatment. While not a few cases of eczema arise from 
purely local causes, and require only external treatment, in 
most cases the patient is not in good condition, and he needs 
treatment quite apart from his skin disease. It is well for 
us to begin our treatment of a case by regarding it as one 
of a sick man rather than a sick skin. The better prac- 
titioner of medicine a man is, the better his chances of curing 
his case will be. It is not the part of the writer on matters 
dermatological to instruct his readers in general medicine, 
and here I can give only an outline of the treatment proper 
to be followed. 

If the patient is anaemic, we should administer iron, and 
see that he has plenty of fresh air and a sufficient amount 
of exercise. If he is run down, and especially if he is of 
a strumous habit, cod-liver oil will be indicated. To the 
nervous patient, strychnine, hypophosphites, and other 



ECZEMA. 171 

nerve tonics should be administered. The dyspeptic needs 
mineral acids, nux vomica, pepsine, or bismuth and soda, 
according to the different form the trouble takes. Those 
suffering from uterine diseases need the treatment best 
suited to their case. The gouty and rheumatic will be bene- 
fited by alkalies, such as the acetate of potash or the phos- 
phate of sodium. Colchicum will be useful in gouty cases. 
In fact, there is no specific for eczema, and each case should 
be studied and treated by itself. 

But nearly every case requires attention to the diet and 
exercise, and to the proper action of the bowels and kidneys. 
The diet is of special importance. Piffard 1 has found that 
56 per cent, of his cases of eczema have been carnivorous — 
that is, eating meat three times a day and but little bread 
and vegetables; 40 per cent, omnivorous, and but 4 per 
cent, herbivorous. Many of the cases eat too much and 
exercise too little. Many suffer from distress of stomach 
after eating certain articles, Some eat too little, and that 
of improper sort. The indications for treatment are there- 
fore obvious. The greatest difficulty to contend with is the 
objection most people have to dieting of any sort. 

In an acute eczema of any considerable extent it is always 
best to put the patient on a restricted and simple diet, and 
of these, where milk is well borne, a milk diet is the best. 
Two or more quarts of milk may be taken during the day in 
divided doses, with dry toast or toasted crackers. After a 
few days a more liberal diet may be allowed, as in subacute 
and chronic eczema. 

In subacute and chronic eczema meat should be taken 
but once a day, and should be beef, mutton, or chicken, 
and these should be eaten in the middle of the day when 
possible. Breakfast and supper should be very simple, of 
crackers and milk, bread and milk, or some of the grains 
well cooked and eaten without sugar. Fish may be allowed, 
but not those with dark meat or oily. An occasional egg 
may be eaten in the morning, but not every day. No 

1 Materia Medica and Therapeutics of the Skin. Wm. Wood & Co., 
N. Y., 1881. 



172 DISEASES OF THE SKIN. 

pastry, cake, or confectionery should be allowed. Apart 
from absolute simplicity the patient's taste may be con- 
sulted, care being taken to avoid anything that he knows 
will disagree with him. It is a good rule to tell the patient 
that he may eat what he likes, but not of more than two 
dishes at a meal. It is unlikely that he will then overeat. 
Those who eat too little for any reason should be directed 
to take that little more often during the day. The dyspep- 
tic should drink a cup of hot water about a half- hour before 
meals. In these cases it is sometimes necessary for a time 
to resort to kumyss or matzoon, and artificially digested 
foods, but the sooner he can return with comfort to a more 
natural diet the better. Fried and warmed-up meats should 
be avoided in all cases. Fruits fully ripe or stewed can 
as a rule be liberally partaken of. 

All alcoholic drinks must be absolutely forbidden. Malt 
liquors are specially obnoxious to all irritable skins. Tea, 
coffee, and chocolate are best let alone. Coffee, one small 
cup, may be allowed for breakfast ; or cocoa, which is better, 
if made with a good deal of milk. Water should be drunk 
regularly, and it is not unlikely that much of the benefit 
derived from visiting foreign spas is on account of the regular 
drinking of water. A good rule is for the patient to drink 
a glass of water before meals, while dressing, a glass of 
water or other fluid at each meal, a glass of water about two 
hours after meals, and before going to bed. If preferred, 
bottled table waters may be used. Vichy water may be sub- 
stituted for plain water once or twice a day. Tobacco is 
harmful in some cases. 

Enforcement of these dietary laws will in many cases over- 
come constipation. It is best not to resort to medicines to 
procure a good daily movement of the bowels, if it can be 
avoided. Kneading of the bowels when in a recumbent 
position will often stand us in good stead, the bowels being 
steadily and deeply rubbed with the heel of the hand, start- 
ing in the right groin, and following the course of the large 
intestine upward, across, and downward. The habit of 
going to stool at a regular hour of the day should be formed, 
and it should be seen to that the bowels act promptly. If 



ECZEMA. 173 

we must needs give medicine, the tablet triturates of aloin, 
belladonna, and nux vomica ; the pill of iron and aloes ; the 
extract of cascara sagrada, with or without nux vomica, 
which may be administered in capsules to avoid the disagree- 
able taste ; Startin's mixture — 

R. Magnesii sulphatis, 2>vj-^jss; 20-30 

Ferri sulphatis, 3j ; 3 



Ac. sulphur, dil., £ij ; 6 

Syr. pruni virgin., %] ; 24 

Aquae, ad ^iv; 100 
Sig. A teaspoonful through a tube, after meals. 



M. 



or any other serviceable remedy may be given. Hardaway 
recommends the phosphate of sodium, a teaspoonful in hot 
water before breakfast, or three times a day, for lithsemic 
patients who are constipated. This is an excellent laxative 
for children, a little of it being put into their milk, to 
which it gives a hardly noticeable salty taste. 

Exercise in the open air is as necessary for our eczema- 
tous patients as for any other class. It should not be taken 
so as to cause over-fatigue. Patients with eczema on the 
face and hands, or with a tendency thereto, should always 
wear gloves during the cold seasons, and should always 
protect the skin of the face by a little powder or vaseline 
before going out into the cold or storm of wind or rain. 

Though there is no specific for eczema, there are certain 
drugs that have acted favorably upon the disease in the 
hands of some observers. Arsenic has come down from 
old with a reputation for curing eczema, and is largely pre- 
scribed. It had best be let alone. It is only of benefit in 
chronic scaling cases, and in only a few of them. It may 
be used in the form of Fowler's solution (Liq. potassii 
arsenitis), giving from 2 to 5 minims well diluted, three 
times a day, after meals ; or as arsenious acid, in tablet 
triturates, either with or without pepper, dose -jfa to ^ 
grain. The wine of antimony in 5-minim doses, three 
times a day, has been warmly commended. Phosphorus, 
To~ff t° 2V grain, either in pill or in oil, has been found use- 
ful in long-standing eczema. Piffard speaks well of an in- 



174 DISEASES OF THE SKIN. 

fusion of Viola tricolor in acute or chronic eczema capitis, 
especially in lymphatic children. It is made by putting one 
or two drachms of the imported herb into a bowl, pouring a 
pint of hot water over it, and covering with a plate. When 
cool, it is to be taken in divided doses during the day. After 
a few days it generally aggravates the disease, a good thing 
to accomplish in chronic cases. It is then to be discontinued 
for a few days or a week. In acute cases the dose should 
be quite small. In infants one drop two or three times a 
day is often sufficient. Adults may take as much as a tea- 
spoonful in chronic, sluggish cases. Turpentine, the spirits, 
is recommended by Crocker in obstinate cases. It is given 
in an emulsion with mucilage, three times a day, after meals : 
the dose being 10 minims at first, and then, if tolerated, in- 
creased by 5-minim doses up to 20 or 30 minims. While it 
is being taken, not less than a quart of barley-water should 
be drunk, and the last dose should be taken not later than 
six o'clock in the evening. The same author recommends 
counter-irritation over the spine, the nape of the neck for 
eczema of the upper half of the body, and over the last 
dorsal and first lumbar vertebrae for the lower half. Dry 
heat, a mustard-leaf, or liquor epispasticus, may be used. 
I have seen most excellent effects from this plan. The 
spinal ice-bag sometimes accomplishes the same result. 

In acute eczema, if taken early, sharp catharsis will 
sometimes tend to lessen the severity of the attack by re- 
ducing the congestion of the skin. In chronic eczema, even 
without evident renal derangement, the acetate of potash in 
15-grain doses will prove useful. The itching may be so 
severe in some cases that even our local remedies may not 
allay it, and it may seem necessary to give some medicine 
to procure sleep. Never use opium. The bromides, chloral, 
or phenacetin may be given. Bulkley recommends tincture 
of gelsemium, of which ten drops are to be given, and re- 
peated and increased every half-hour till relief is obtained, 
or constitutional symptoms of languor, tranquillity, dizzi- 
ness, impairment of vision, and drooping of the lids, are 
produced. Quinine, in J-grain to 15-grain dose given at 
bedtime, is commended by some for the same purpose. 



ECZEMA. 175 

Local Treatment. In all cases, whether due to purely 
local causes or a combination of these and some general 
cause, local treatment is of the greatest importance. The 
books teem with prescriptions which have been found effi- 
cacious, and some of them contain so many ingredients that 
it is hard to determine with exactness to what the good is 
due. After all, the matter is very simple, and, if the prin- 
ciples are mastered, little difficulty will be found in accom- 
plishing the desired end. In acute cases, where we have 
heat and swelling, employ soothing remedies ; in subacute 
cases, where the swelling has subsided and where the papu- 
lation, vesication, pustulation, or exudation is more or less 
active, use astringent and slightly stimulating remedies ; in 
chronic cases, where we have thickening with scaling, stimu- 
late; in all cases protect the skin from external irritation. 
It is better to learn how to use a few remedies and to know 
what to expect from them than to try every new method 
that appears in the medical press. 

It is a good, broad rule that water should not be used on 
an eczematous skin, as it removes the newly formed epi- 
dermis and exposes the tender skin to the air. In all but 
chronic cases it should be used sparingly, and only to re- 
move dirt, or crusts, or scales, and the skin should be at 
once covered with some protecting powder or ointment. If 
water is used, it should be either rain or boiled water, or 
water with a little soda, one drachm to the basinful, or bran 
in it. Often it is better to clean the skin with an oily 
lotion than to use water. 

In acute eczema lime-water, liquor plumbi subacetatis 
dil., lead and opium wash, or solutions of borax or soda, one 
or two drachms to the pint, may be sopped on three or four 
times a day, dusted over with cornstarch, bismuth, lycopo- 
dium, kaolin, or French chalk, and covered with light, old 
linen or muslin. All these will allay the itching, but if this 
is especially severe the following may be used : 



R. Oamphori, ^ss; 3 

Zinci oxidi, 3 ij ; 15 

Amyli, 3iv; ad 30 



M. 



176 DISEASES OF THE SKIN. 

Startin recommends the following: 

R . Zinci oxidi, % ss ; 6 

Pulv. calaminse prep., 9iv; 2 

Glycerini, t ^j ; 12 

Liq. calcis, 3 v ij; a( l 1^0 M. 

As soon as the early and most acute stage is passed, that 
is, in the subacute eczema, a protecting and soothing oint- 
ment is to be used, and of these no one is safer than the 
standard benzoated oxide of zinc ointment that usually can 
be obtained anywhere. The cucumber ointment is also 
soothing. If the case be one in which there is much dis- 
charge, as in pustular, vesicular, and weeping eczemas, 
Lassar's paste is better than the oxide of zinc ointment, as 
being a paste it allows the discharge to percolate through 
it. It is made as follows : 



R. Zinci oxidi, 1 „.. Q 

Amyli, I aa £ij; 8 

Vaselini, ^ ss ; 16 



M. 



The addition of 10 or 15 grains of salicylic acid to the 
ounce increases its anti-pruritic quality. The only difficulty 
is that it takes time and muscle to make, and but few drug- 
gists make it well. See that in it, as in all other ointments, 
there are no gritty particles left. All ointments must be 
smooth, or they do harm rather than good. In using oint- 
ments in eczema they should be evenly spread upon cheese- 
cloth folded four times, or upon old linen or muslin, in a layer 
as thick as the back of a table knife blade, applied to the 
affected part and bound down snugly with a bandage. They 
should be changed twice a day, or more often if the dis- 
charges are profuse. 

Painting a limited moist patch of eczema with a solution 
of nitrate of silver, 3 to 10 grains to the ounce, is often a 
most prompt method of curing the disease. 

Ointments are objectionable on account of their greasi- 
ness, and where possible it is pleasanter to use lotions. Of 
these one of 



. Calamin. 


By; 


101 




Zinci oxid., 


3 ss ; 


6 




Glycerini, 


m*v ; 


3 




Liq. amygdalae co., 


3j; 


1001 


M 



ECZEMA. 177 

answers well. Peroxide of hydrogen sopped on exercises a 
beneficial effect on pustulation. 

The diachylon ointment will often prove beneficial, espe- 
cially after the subsidence of acute symptoms. It is best 
used diluted with ungt. aqua rosse in the proportion of two 
parts to one. Most cases that we are called upon to treat 
are in or near to the subacute stage, as the acute stage soon 
passes off. It is always advisable to begin treatment not 
too boldly. If our protecting and astringent remedies do 
not cure the case after a fair trial, then we must add stimu- 
lants, and of these one of the most reliable is tar, adding it 
at first in the proportion of about fifteen drops of the oil of 
cade to the ounce of ointment-base, such as oxide of zinc 
ointment. 

In chronic squamous eczema we need stimulation to whip 
up the circulation, to produce absorption of the infiltration 
of the skin, and to promote a return to health. Here tar 
is one of our most reliable remedies, and it can be used in 
various strengths and ways. We may use the oil of cade, 
oleum cadini, the oil of birch, oleum rusci, or pix liquida. 
There are some doubt and difficulty about obtaining genuine 
oleum rusci, which is largely used by tanners in the prepa- 
ration of Russia leather. The oil of cade is most used. Some 
prefer this ointment : 



&. 01. cadini, 5 ss ~j>\ 

-j ; J 



aa 2-4 



Zinci oxidi, 3i ss- j 

Unguenti aquse rosae, ^j ; 30 M. 

Or the cade may be added to the oxide of zinc ointment in 
the proportion of a drachm to the ounce. Or pix liquida 
may be substituted in about double the strength. 

Another most excellent way of using tar, and preferable 
to the latter because not so liable to stain the clothing, is 
that proposed by Pick, namely : To make a strong tincture 
of tar, using 40 parts of pix liquida to 20 parts of alcohol. 
To paint the part every night with three coats of this 
tincture, letting each coat dry on before another is applied. 
Then cover with oxide of zinc ointment ; the ointment being 
changed morning and night. 



178 DISEASES OF THE SKIN. 

Bulkley in some cases recommends tar in what he names 
liquor picis alkalinus, which is made as follows : 



R . Picis liquidse, ^ ij ; 25 

Potass, causticse, §j ; 12 

Aquae, ^v; ad 100 



M. 



Dissolve the potash in the water and add slowly to the tar 
in a mortar with friction. This is to be used diluted twenty 
or more times with water, and followed by oxide of zinc 
ointment. 

In some very chronic, thickened eczemas the tar may be 
rubbed in pure. If the eczema is very extensive, the tar 
may be used in olive oil or cotton-seed oil and smeared over 
the body. In some cases the tar will give rise to systemic 
poisoning, the urine will become black, and the patient will 
suffer from headache, oppression, nausea, vomiting, and 
diarrhoea, and the pulse will become frequent. Of course, 
under these circumstances the tar must be stopped. 

Sulphur is, next to tar, one of our best stimulating reme- 
dies in squamous eczema. It is not so reliable, as it is more 
uncertain in its effects. Its finds its best use in circumscribed 
patches, and may be used in vaseline or simple ointment in 
the strength of one or two drachms to the ounce. In some 
skins it produces a good deal of dermatitis. 

G-reen soap is often of the greatest service in chronic 
eczema. It is to be used in the following way : Take either 
the green soap or Bagoe's prepared olive soap ; warm water ; 
and oxide of zinc ointment spread on muslin or linen. Dip 
a piece of flannel in the soap and then in the water, and 
then with it scrub the part vigorously until all the scales 
are removed and the skin looks somewhat raw. Now wash 
off all the soap with plenty of water, dab the part dry with 
a soft towel, immediately cover with the ointment, and apply 
a bandage. The soap is to be used once a day and the oint- 
ment changed twice a day. 

Caustic potash, 15 grains to 1 drachm to the ounce ; or 
salicylic acid, 10 to 15 per cent., in ether may be used to 
reduce very much thickened patches. Nitrate of silver, 10 
to 15 grains to the ounce, may also be used. 



ECZEMA. 179 

Unguent, hydrarg. ammoniat., diluted to half its strength, 
is of use in chronic eczema of limited area. 

Ichthyol and resorcin are two of the more recent addi- 
tions to our armamentarium. The former has a more dis- 
agreeable odor than tar, and as Crocker says of it: "We do 
not want more of such remedies, as tar fills that place so 
well ; what is required are remedies which do not stain nor 
smell.'' Kesorcin in from 2 to 5 per cent, strength is a good 
stimulating application. 

For the reduction of infiltration and removing the scales 
in a chronic eczema nothing is better for a time than sheet 
rubber applied to the part and bound down with a roller 
bandage. The rubber should be removed once a day, 
sponged off with soda and water, and reapplied. The re- 
lief to the itching procured by this means is sometimes sur- 
prising. As soon as the infiltration is reduced we should 
resort to our tar remedies for completion of the cure. 

Many attempts have been made to find a substitute for 
greasy or oily applications in the treatment of skin diseases. 
Thus we have the plaster mulls of Unna, in which a plaster 
mass is incorporated with the mulls. Many speak loudly in 
their praise. Then collodion and traumatieine have been 
used, and answer well, the tar, salicylic acid, or what not, 
being dissolved or held in suspension. In this way chrys- 
arobin may be used on limited patches of chronic eczema. 
G-elatin preparations have been introduced, but they take so 
long to dry as a rule that they have not become popular 
in this country. Bassorin "paste and plasment have been 
recently brought out, and promise well. Medicated soaps 
have their advocates. I have had no experience with the 
last. 

In the treatment of eczema we must not content ourselves 
by simply giving our patient an ointment, but we must in- 
struct him in the way he should use it. As a rule, and 
where possible, all our ointments should not be smeared on 
the skin, but spread on old linen, muslin, or the like, and 
bound down with a bandage or with a ring of elastic web- 
bing. In chronic patches it h is well to rub in our tar or 
other ointment. 



180 DISEASES OF THE SKIN. 

Massage sometimes does good service in reducing in- 
filtration, the part being stroked upward in the course of 
the circulation. 

Baths are not usually advisable in eczema, and are ap- 
plicable only to chronic cases. Good results have been 
reported from some sulphur baths. Residence at the sea- 
side generally proves bad for eczematous patients, but it 
may be a good thing for some run-down patients, the tonic 
effect of the sea air out-balancing the evil effect of the 
dampness. Soda, borax, or bran baths will prove grateful 
in some cases. Bulkley orders the following : 

Be . Potass, carbonat. , ^ iv ; 

Sodii carbonat, ^iij ; 

Boracis pulveris, ^ ij ; M. 

Add to thirty-gallon bath with half a pound of starch. 

Prognosis. We can give assurances of curing eczema so 
far as the attack with which the patient comes to us is con- 
cerned. We can give no positive assurances that the disease 
will not return. The cure of the attack requires patience, 
careful study of the case, and the intelligent use of remedies. 
But there are some cases that are exceedingly rebellious. We 
have to accept the fact that some people are " eczematous," 
and that they cannot be permanently cured unless they are 
regenerated. We should cure our cases as rapidily as pos- 
sible, and not take refuge in the excuse of the incompetent 
man and tell the patient that it is dangerous to cure it. 

We must now consider Regional Eczema. 

Eczema Ani, as usually met with, is of the squamous, 
thickened variety with Assuring. It may also be moist. 
It usually extends up the whole internatal fold. It gives rise 
to great pain in defecation and to much itching at all times. 
The discharge from this form, as well as from eczema of 
the genitals, is frequently offensive. Excessive use of to- 
bacco predisposes to this variety of eczema, probably on 
account of the nervous irritation inducing itching, for the 
relief of which the patient scratches and produces the 
eczema. 

In treatment the first thing is to stop the use of tobacco, 



REGIONAL ECZEMA. 181 

a hard task, as the patient is ofttimes incredulous of its effi- 
cacy. Horseback-riding and much walking will sometimes 
have to be stopped, as they may aggravate the trouble. If 
hemorrhoids or fissures of the mucous membrane are present, 
as they quite frequently are, they must be cured in order to 
obtain a permanent cure of the eczema. The bowels must 
be kept easy by laxatives so that one soft movement may 
be had each day. Liver derangements must be corrected 
to prevent portal congestion, and dieting will be of service. 
The nates must be separated by folds of lint, and the parts 
kept scrupulously clean, though water should be used as 
sparingly as possible. The itching may be relieved by sop- 
ping on hot water, dabbing the part dry, and making the 
chosen application. Tar or diachylon ointment may be 
used, all covered in with a dusting-powder. Usually the 
drier the parts can be kept and the less ointment is used the 
better. Painting a limited surface with salicylic acid, 10 
to 15 grains in an ounce of flexible collodion, is often fol- 
lowed by the happiest results. Painting with nitrate of 
silver, 10 to 15 grains to the ounce, is sometimes advisable. 
Here, too, if there is much thickening, wearing rubber 
cloth for a few days will greatly hasten the cure. A well- 
applied T-bandage is the best way of keeping the dressings 
in place. 

Eczema Aurium. Eczema may affect both the ear itself 
and the inside of the auditory canal. When the ear is 
acutely affected it is swollen at times so much as to stand 
out from the head. In acute eczema of the external audi- 
tory canal, which is secondary to that of the auricle, the 
swelling may be so great as to cause dulness, if not loss of 
hearing. Of eczema of the outer part of the ear nothing 
special need be said excepting that the dressings must be 
exactly applied to all the little furrows of the ear, and a 
pledget of lint placed in the furroAv behind the ear, thus 
separating it from the side of the head, so that in sleeping 
the two surfaces of skin do not come into contact. Paint- 
ing this part of the ear with a solution of nitrate of silver, 
ten grains to the ounce, will sometimes aid greatly in con- 
verting a moist eczema into a squamous one. During the 

9 



182 DISEASES OF THE SKIN. 

day a cure will be hastened by having the ear covered with 
a linen bag made in the fashion of an ear-muff. Eczema 
of the auditory canal is sometimes very annoying on account 
of an accumulation of scales, dulling the hearing. For this 
condition an ointment of tannin, one drachm to the ounce, or 
a solution of nitrate of silver, 5 to 20 grains to the ounce, 
may be applied thoroughly by means of absorbent cotton 
on a probe, the ear being properly lighted by means of 
a head-mirror, and the operator having the requisite skill. 
Otherwise the tannic acid ointment, or one of oxide of zinc, 
or the diachylon ointment may be applied on pledgets of 
lint rolled up to fit the orifice. The insufflation of boric 
acid will sometimes be better yet. The ear should not be 
syringed out often, and when it is necessary to do so a 
solution of borax or soda should be used. 

Eczema Barbce is scarcely ever confined to the bearded 
portion of the face, but it generally runs over on to the 
bordering skin, and is often but a part of eczema of the 
face. It has practically the same symptoms as has eczema 
capitis. It needs to be diagnosticated from ringworm and 
sycosis, which see. In treatment, shaving, or cutting the 
hair close, which is better, should be practised so that 
remedies may be closely applied. Plucking the hair from 
the pustules is to be recommended. Its further treatment is 
the same as that of Eczema capitis. It is an obstinate form 
of eczema, prone to relapses. 

Eczema Capitis. The scalp is very commonly the seat of 
eczema either by itself or in connection with eczema else- 
where. It has received various names, such as crusta lactea ; 
porrigo ; melitagra ; scalled head ; milk crust ; or vesicular 
or running scall. While any variety of eczema may occur 
on the scalp, the vesicular is very rarely seen, and the most 
common is the pustular, and the final stage, the squamous. 
In the acute stage the scalp may be swollen and boggy, and 
moist, with the hair stuck together. Usually we find the 
scalp crusted with a yellowish serous crust, but more com- 
monly with a greenish or blackish purulent crust, while the 
scalp is swollen but little. In some cases of pustular eczema 
there will be discrete, rather large pustules scattered 



REGIONAL ECZEMA. 183 

through the hair, besides moist and crusted patches. The 
hair is always matted together, and the odor from the scalp is 
unpleasant. If the crusts are removed, they will soon re- 
form. 

In both the erythematous and squamous forms the scalp 
is red and scaly. In the latter variety there is apt to be 
more or less thickening of the scalp, and in very severe 
cases the scalp may be cracked. Not infrequently there 
will be squamous patches in some places and moist and 
crusted patches in other places. 

With eczema of the scalp there is almost always eczema 
behind the ears. The cervical glands are very often swol- 
len, especially in children, but they need give no anxiety, 
as they very rarely suppurate. In the chronic form there 
may be loss of hair, especially in children, when it is some- 
times mechanically rubbed off from the occiput- It is never 
permanently lost. All forms are itchy, the pustular form 
least so. The patient may complain of a u drawn" feeling 
of the scalp. As in all inflammatory diseases of the scalp 
there is over-activity of the sebaceous glands, and the crusts 
will contain a certain amount of fat. In chronic cases there 
may be, on the other hand, a deficiency of fat. Pediculi 
are often found on the hair. The disease may affect the 
whole scalp or only a portion of it, and may run an acute 
or chronic course. 

Etiology. The exciting causes of eczema capitis are all 
irritants to the scalp. Sometimes it is well-meant but badly 
directed efforts at cleanliness, especially in children. Comb- 
ing with a fine-toothed comb, too vigorous use of soap and 
water, the use of a too stiff brush, are some of these. 
Pediculi are very often the cause — not the pediculi them- 
selves, but the scratching to relieve the itching produced by 
them. An eczema of the occiput should always suggest 
their presence, and search then will generally reveal the 
pediculi or their nits upon the hair. Sometimes remedies 
used to kill the lice will set up an eczema, such as strong 
mercurial ointments. In most cases eczema of the scalp is 
but a part of a more or less general eczema and due to the 
same causes. 



184 DISEASES OF THE SKIN. 

Diagnosis. The disease must be differentiated from 
pityriasis capitis, ringworm, erysipelas, lupus erythematosus, 
a dermatitis, psoriasis, seborrhoea, favus, pediculosis, and 
syphilis. See under these diseases. 

Treatment. The treatment of eczema capitis is along 
the same lines as is that of the disease in general. On the 
scalp it is always best to use our remedies either in vaseline 
or oil, as preparations of lard make a disagreeable mess 
with the hair. Nor should a thick ointment ever be used, 
excepting perhaps in children before their hair is grown, or 
on bald heads. If there are crusts on the scalp, they must 
be removed before any local treatment is used. This may 
be done best by soaking them with oil for twelve or twenty- 
four hours, and then washing them away with soap and 
water. Plenty of oil must be used, and it is well to tie the 
head up in a towel over night. A woman's or half-grown 
girl's hair should never be cut in order to treat the scalp. 
In applying remedies to the scalp, after the acute stage, they 
should be rubbed in and not merely smeared over it. 

In acute eczema equal parts of lime-water and sweet or 
almond oil, with or without two per cent, of salicylic acid, 
forms a good application. 

In subacute and chronic eczema of the scalp, tar, especially 
the oil of cade, is our most reliable remedy. It must be re- 
membered that it can be used much earlier on the scalp than 
elsewhere, and most cases will improve under it as soon as 
the acute stage is passed. It may b3 begun in the strength 
of twenty drops to the ounce of oil, and increased to one or 
two drachms to the ounce. Many people object to the odor 
of the tar. We can substitute for it : 



Or, 



K . Hydrarg. amnion. , gr. xx ; 5 

Vaselini, ^j ; 100 

K . Ac. salicylici, gr. xx-xxx ; 5-6 

01. olivaj, 5j ; 100 



M. 



M. 



The oil of cajuput in five to ten per cent, strength may be 
tried. Neither of these is as good as tar. 

If the disease is in a chronic condition, shampooing with 



REGIONAL ECZEMA. 185 

green soap or its tincture, followed by some oily, not very 
stimulating application, will prove curative. In this condi- 
tion it is sometimes best to exhibit the tar in an alcoholic 
solution. Resorcin in three to ten per cent, strength may 
be used cautiously in this way. If the scalp is cracked and 
thickened, great and prompt amelioration will be secured by 
having the patient wear a close-fitting cap of rubber. 

Eczema Crurum. Eczema of the legs acquires its pecu- 
liarities from the fact that the circulation of the parts is less 
active than it is in the upper portions of the body, on ac- 
count of the action of gravity upon the returning venous 
blood. It usually is seen as an eczema madidans. though 
any form may be present. Varicose veins, either superficial 
or deep, predispose to it. Pigmentation of more or less 
dark-brown color follows or accompanies it, if of any chron- 
icity, and occasionally purpuric spots will be scattered about 
the chronic patch. In treatment nothing special need be 
said except that it is always advisable to have the legs ban- 
daged snugly from toes to knee, and that the best result will 
be attained when the bandaging is done by the doctor or a 
trained nurse. 

Eczema G-enitalium often causes a great deal of discom- 
fort on account of the excessive itching that accompanies it. 
It affects the scrotum most commonly, which in some cases 
will be greatly thickened and feel like leather. The skin 
of the penis also suffers at times as well as the glans. In 
women, both the lesser and the greater lips of the vulva, as 
well as the entrance to the vagina may be affected, and show 
excoriations and thickening. All forms of eczema may be 
encountered in the genital region. In chronic eczema of 
the penis the organ becomes greatly enlarged both laterally 
and longitudinally, on account of the thickening of the skin. 
The disease may be confined to the genitals or extend to the 
thighs, or the anal region. The presence of diabetes should 
always be suspected in a case of this kind, and the urine 
should be examined for sugar. Leucorrhoea is a common 
cause of the disease in women. 

Treatment. In the treatment of eczema of the genitals, 
apart from that due to general conditions and specially to 



186 DISEASES OF THE SKTN. 

diabetes, it is essential that men should wear a well-fitting 
suspensory bandage, inside of which the dressing may be 
placed. The itching may be greatly relieved in all forms 
by directing the patient to sit over a vessel containing hot 
water and to sop the water up on the parts. The skin 
should be mopped dry, the oxide of zinc ointment, diachy- 
lon ointment, or Lassar's paste immediately applied, and 
the suspensory bandage adjusted. Carbolic acid, one or two 
drachms to the ounce of glycerin and water, may also be 
used, lightly dabbed on, for the purpose of allaying the itch- 
ing. It should be followed by either of the above ointments. 
For chronic, thickened eczema wearing sheet rubber inside 
of the suspensory bandage will give positive and immediate 
relief, and greatly reduce the thickening. After a few days 
it is well to follow it with a tar or resorcin ointment. In 
some cases nothing will do so well as the application of the 
nitrate of silver solution, already given. The spirits of 
nitrous ether may be used as an excipient of this. Hard- 
away speaks highly of rubbing the scrotum with a solution 
of salicylic acid in alcohol, one drachm to the ounce, and 
following this with a boric acid or diachylon ointment. 

Women should use a T-bandage instead of a suspensory. 
Otherwise the treatment is the same. In them I have seen 
the nitrate of silver treatment do remarkably well. 

Eczema Intertrigo occurs wherever folds of skin come 
into contact, and requires that the parts should be kept 
separate and as dry as possible by means of a dusting- 
powder, or by placing a piece of old linen or cheese-cloth 
between the apposed folds of skin. For a dusting-powder 
we may use either cornstarch alone or with bismuth, or 
zinc oxide. Lycopodium is also an excellent powder. The 
disease often resembles an erythema, but inasmuch as both 
diseases are amenable to the same treatment, absolute accu- 
racy of diagnosis is not essential. Kaposi has seen gan- 
grenous and diphtheritic inflammation begin in an intertri- 
ginous eczema. As a rule, these cases do best without 
ointments. This does not apply to eczema intertrigo of 
the crotch. Here it is well to cover the parts with a greasy 
application so as to protect them from the action of the 



REGIONAL ECZEMA. 187 

urine. A dilute diachylon ointment often answers ad- 
mirably. 

V 

Eczema Labiorum is usually due to a nasal catarrh, and 
can be cured only when the cause is removed. Eczema may 
occur all about the mouth in an orbicular manner. Many 
people suffer from chapped lips, especially in winter. This 
is an eczema of the vermilion border. For this little can 
be done except to caution the patient against moistening the 
lips. Greasing the lips every night with camphor-ice or 
the like keeps them in good condition. Glycerin agrees 
well with some skins, and is harmful to others. Cracks 
may be touched with the nitrate of silver stick, and the lip 
painted with compound tincture of benzoin. 

Eczema Mammarum et Mammillarum. One of the 
most annoying accidents to befall a nursing woman is eczema 
of the nipples. They become excoriated and fissured, the 
cracks sometimes extending to the base of the nipple. At 
times a drop of pus can be squeezed from the bottom of the 
crack. They are exquisitely sensitive, and every time the 
baby takes hold the woman suffers agony. The moisture 
from the child's mouth and the decomposing milk left on 
the nipple aggravate the trouble. Mastitis may complicate 
matters. In the intervals of nursing the nipple scabs over. 
Either one or both nipples may be affected. The disease 
may extend on to the breasts, or the breasts may be affected 
independently of the nipples. Women with pendulous and 
heavy breasts frequently suffer with a moist eczema in the 
sulcus beneath them. Apart from this nothing special need 
be said about eczema of the breasts. There is one disease 
of the breasts, called Paget's disease of the nipple, which 
at first very closely resembles eczema, and it is a question 
whether it is carcinomatous all the way through, or an 
eczema developing into a carcinoma. (See Paget's Disease 
for diagnosis.) 

Treatment. It is often possible to cure eczema of the 
nipples even while the child nurses. Sometimes it will be 
necessary to wean the child. Women during the latter 
months of pregnancy should handle their nipples every day 



188 DISEASES OF THE SKIN. 

and bathe them with whiskey or alcohol, to which may be 
added 20 or 30 grains of borax to the ounce. This will 
do much to prevent future trouble. The suckling having 
begun, the nipples should be carefully washed off and 
dried with a soft handkerchief after each nursing, and 
dressed with oxide of zinc or diachylon ointment, should 
eczema show itself. Of course, the ointment should be 
removed before the infant is put to the breast, and this 
should be done with as little water and as much gentle- 
ness as possible. If there are cracks, the child should 
nurse through a rubber nipple, and when it lets go the 
nipple should be dried and painted with compound tinc- 
ture of benzoin, or the solution of nitrate of silver already 
spoken of. It is also advised to touch the cracks with 
the nitrate of silver stick. This is very painful, and of 
little use as long as the infiltration of the nipple that causes 
them continues. The nipples may be washed with a borax 
solution and covered with an ointment of borax. It is always 
advisable to use nothing that is poisonous in the dressings. 
Hardaway recommends the following for eczema under the 
breasts : 

B= . Thymol, gr. j 

Pulv. zinci oleat., ^j. M. 

Eczema Manuum. Eezema of the hands has been called 
u washerwoman's itch," " grocer's itch," " bricklayer's itch," 
and various other itches. It is in many cases a trade eczema, 
caused by strong alkaline soaps, or contact with sugar, mortar, 
or other irritant. It may arise independently of any of these 
trade causes, or it may be part of a general eczema. The 
acute forms, as they occur upon the backs of the hands, do 
not differ from the same on other parts of the body, and the 
same may be said of the chronic forms. The palms are 
seldom primarily affected, but secondarily to eczema of the 
wrists or fingers. The epidermis of the palms, as well as 
that of the palmar surfaces of the fingers, is thicker than 
that of the other parts of the body, excepting the soles of 
the feet, and so the vesicles do not rupture readily, but are 
seen like little, more or less translucent grains under the 



REGIONAL ECZEMA. 189 

skin. When they rupture, the skin is left more or less 
ragged and worm-eaten. The skin over all the joints is 
liable to crack and form painful fissures. Chronic eczema 
of the palms prevents free movement of them on account of 
the thickening and the painful cracking. The skin is red- 
dened and covered with large adherent scales. Itching is 
intense at times. The whole palm may be affected, or the 
disease may form limited areas, as upon the centre of the 
palm, over the thenar eminence, and upon the finger-ends. 
This form of eczema is often difficult of diagnosis from the 
squamous syphilide. The occurrence of the lesions upon 
one hand alone should rouse suspicion of syphilis, especially 
if little or no itching is complained of. 

Tkeatment. It is one of the most obstinate of eczemas 
to treat, when of chronic form, and requires active stimula- 
tion by means of tar ; salicylic acid ; the soap and salve 
treatment ; rubbing in 5 to 10 per cent, of the oleate of 
mercury ; or painting with caustic potash. The constant 
wearing of rubber gloves is excellent for the purpose of soft- 
ening the skin and preparing it for other remedies. It is 
best to buy the canvas-lined gloves, turn them inside out, 
and wear the rubber next the skin. The hands must be 
kept out of water. Where this cannot be done, great care 
must be used in drying them. It is well to have the patient 
dry on two towels or before the fire, and then either to thrust 
the hands in a box of cornstarch powder or flour, or prefer- 
ably to apply the proper dressings. Acute eczema of the 
hands is treated the same as an eczema elsewhere. Unna 
teaches that eczema of the hands and fingers is always 
secondary to eczema seborrhoicum capitis. He recom- 
mends in the disease, as it affects cooks, housemaids, and 
the like, that the hands, on going to bed, should be washed 
with green soap and water when the eczema is of squamous 
form, and with a weaker soap when it is moist. Then a 
paste of 

Oxide of zinc, 40 parts ; 

Chalk, 1 

Lead water, > aa 20 " 

Linseed oil, J 

9* 



190 DISEASES OF THE SKIN. 

or one of 

Oxide of zinc, 1 

Sulphur, 

Chalk, [► aa 20 parts. 

Linseed oil, 

Lime water, J 

is to be well rubbed, in. Before using the paste when the 
eczema is moist it should be powdered with flour. The 
paste is covered with the thinnest rubber tissue, such as is 
used for bouquet handles. This will stick well. Cotton 
gloves can be worn at night. In the morning the dressing 
is not to be removed until the worst of the work is done. 
Then it is to be washed off, and a little of the paste applied 
until time for the evening dressing. 

In eczema of the hands of masons, washerwomen, and the 
like an endeavor must be made to thicken the corneous layer 
of the skin by dressing them at night with a paste of 

Resorcin, \ aa 10 t 

Ungt. zincioxid, / P 

Terrse silicese, 2 " 

and applying oil or vaseline over it. In the morning the 
hands are not to be washed, but anointed with some oil. 
After a time the corneous layer thickens and the old skin 
falls off. 

Eczema Narium is often, if not always, associated with a 
chronic rhinitis. It is very obstinate. Crusts form on the 
inside of the nose, are picked off, re-form, and after a time 
ulcers result from the constant irritation. Sometimes in 
adults the disease locates itself about the hair follicles, and 
is very annoying. It is a not uncommon point of departure 
for recurrent attacks of facial erysipelas. If long continued, 
it gives rise to a thickening of the upper lip. Furuncles 
sometimes complicate matters. 

In the treatment of these cases the first attention must 
be given to the cure of the rhinitis. Then all crusts must 
be removed by soaking with oil. For the eczema we may 
use: 



REGIONAL ECZEMA. 191 

K • Glycerole plumbi subacetat., \ .. 

Ungt. aquae rosse, J "' " M. 

as recommended by Hardaway. 

Herzog 1 recommends the yellow oxide of mercury oint- 
ment, or equal parts of ungt. plumbi and vaseline, spread 
on lint and accurately applied to the diseased part. Unna 
rolls his zinc and red precipitate ointment muslin into a 
pledget and introduces it into the nose. In obstinate cases 
about the hairs, epilation by electrolysis may have to be 
performed. 

Eczema Palpebrarum is usually of an erythematous char- 
acter, and occurs as part of the same disease elsewhere. 
Eczema of the cilise, also called blepharitis ciliarisj is always 
pustular. The edges of the lids are swollen, rounded, and 
more or less thickly strewn with pustules or crusts. The 
lids stick together on waking in the morning. In the 
squamous form the edges of the lids are merely red and 
scaly. It is almost always symmetrical, occurs usually in 
strumous subjects, and is due to conjunctivitis. 

Treatment. The lids should be anointed before going 
to sleep in order to prevent their sticking together. I have 
always found the following ointment, as given by my friend, 
Prof. D. Webster, of the New York Polyclinic, most ex- 
cellent : 

R • Ac. salicylici, gr. x ; 8 

Ungt. hydrarg. oxid. rubra, ,^j ; 5 

Ungt. aquse rosee, 3^1 30 M. 

An ointment composed of — 

R . Hydrarg. oxid. flav., gr. ij-viij ; 

Vaselini, 3 j . M. 

is recommended by Hardaway. Resorcin, 3 grains ; cold 
cream, 2J drachms, is editorially commended in the Mo- 
natsJiefte f. praht. Dermat., 1888, vii. 1057. Whatever is 
used, we must be sure that any substance entering into it 
is in an impalpable powder, so as to avoid the possibility of 

1 Archiv f. Kinderheilk. , 1887, p. 211. 



192 DISEASES OF THE SKIN. 

getting anything gritty into the eye. Epilation may be 
necessary in some cases. Solutions of bichloride of mer- 
cury (0.05 to 500) are commended both for the conjunctivitis 
and the eczema dependent upon it. In any event the con- 
junctivitis must be treated. 

Eezema Pedum. Eczema of the soles of the feet, though 
not so common as that of the palms, presents the same 
symptoms and calls for the same treatment. The greatest 
difficulty will be encountered in dressing the toes propeily. 
For this the ointment should be spread upon a long and 
narrow strip of lint, the centre of the strip placed against 
the big toe, and the strip wound in and out between the 
toes. A piece of salve muslin may be substituted for this 
with advantage. A piece of rubber sheeting cut to fit the 
sole and bound down with a bandage takes the place of the 
rubber glove. 

Eczema Unguium. Eczema may affect the nail-fold alone, 
and the nail may be scarcely diseased, or the matrix and 
bed may be diseased, when the nail will lose its lustre, and 
become rough, uneven, striated, and atrophied. Only one 
nail may be diseased or all of them may be. The nail may 
be depressed in the centre and turned up at the end with 
an accumulation of scales under its free border. Usually 
eczema of the nails occurs as a part of a general eczema, 
but it may occur as an independent disease. The fleshy 
parts about the nails usually present signs of inflammation, 
and often of an evident eczema. 

It is best treated by means of cots made of rubber. It 
must be remembered that an ointment can never be used 
when rubber is, as it rots it. If the time has come for an 
ointment, linen or leather cots must be substituted for the 
rubber ones. The ointment to be used will depend upon 
the condition of the skin about the nails. 

Universal Eczema is uncommon, and when it does occur 
it is usually of the erythematous or squamous variety, with 
a tendency to cracking in the skin creases of the joints, 
exudation, scaling, and itching. These symptoms will serve 
to distinguish it from dermatitis exfoliativa, to which it 



ECZEMA INFANTILE. 193 

bears a strong resemblance. Constitutional disturbances, 
such as fever and chills, loss of appetite, and digestive dis- 
orders, are not uncommon in these truly pitiable cases. 
Furunculosis is apt to complicate matters. The patients 
are slow in recovering and are apt to be a good deal pulled 
down by the disease. 

Treatment. These patients should be put to bed and 
the underlying cause searched for, and if possible removed. 
They are best treated locally by lotions, oils, or vaseline. 
The ordinary Carron oil, equal parts of linseed oil and lime- 
water ; cotton-seed oil with carbolic acid, 1 part of acid to 
60 of oil ; or simply smearing the body with vaseline and 
powdering on cornstarch, will each relieve. Salicylic acid 
in oil, 1 in 30, will also allay the discomfort. Alkaline 
baths, warm, and followed by one of the above, after tapping 
the skin gently dry, will also relieve, but the bath should 
not be used more than once a day. Its temperature should 
be about 98° F. ; it should last ten or fifteen minutes. 
Bulkley recommends anointing the skin, before drying it, 
with — 



&. Acid, carbolici, Bj - 3ij; 3-16 

Glycerite amyli, ^i y l 100 



M. 



applying it freely. The best way of drying the skin is to 
envelop the patient in a warm sheet, and pat the skin dry. 
As the intensity of the eczema lessens, the frequency of the 
baths must be reduced. It will gradually cease from being 
universal and become localized in patches. 

Eczema Infantile presents certain peculiarities that war- 
rant its being considered as a special variety of eczema. It 
is very prone to be of the pustular form, following the rule 
that in delicate or debilitated subjects an eruption upon the 
skin is apt to be pustular. While in adults eczema of the 
face is usually erythematous, in infants it is nearly always 
pustular. In them it is quite common, if not the rule, to 
have several regions affected at once, such as the scalp, the 
face, and the region of the crotch. In them, also, we have 
eczema madidans in these regions. While in adults that 
form of eczema is most frequently seen upon the legs, in 



194 DISEASES OF THE SKIN. 

infants it is quite exceptional there. Eczema of the scalp 
in infants presents itself as a thick crust formed of puru- 
lent matter, epithelial debris, and sebaceous matter. This 
is called " milk crust." When the crust is raised the scalp 
will be found to be thickened, swollen, boggy, and moist, 
with a purulent secretion. The whole scalp may be affected, 
or only the vertex. With it there will nearly always be a 
moist surface behind the ears, even though the face may be 
comparatively or absolutely free. The lymphatic glands 
will be swollen, but they seldom suppurate. When the face 
is affected it will sometimes be studded over with holes, 
superficial ulcerations, which, however, never leave scars. 
This appearance is seen very rarely in adults. It is often 
striking to note that the skin about the mouth and nose, 
and below the eyes, is in perfect health, though pale, while 
all the rest of the face may be involved in the most intense 
inflammation. The creases of the neck, the flexures of the 
joints, and the region of the genitals usually show an erythe- 
matous or a moist intertriginous eczema. At times the whole 
body will be affected with a general, but very rarely with a 
universal eczema. While the pustular and intertriginous 
forms of eczema are the most common, we may have all 
forms present at one time. The papular form is also fre- 
quently met with alone. Itching is usually severe, keeping 
the little patient awake at night, and the tearing made by 
the nails to relieve the itching gives rise to immense exco- 
riations, especially of the face. Unrelieved the little patients 
sometimes become pitiable objects on account of loss of 
sleep and constant nervous excitement. 

Etiology. There are several causes tending to eczema 
in infants. Their skin is vulnerable to all irritants. When 
we consider that the child is born into the cold world sud- 
denly, and launched there out of a warm atmosphere, in 
which it was surrounded by an alkaline fluid, covered over 
with a fatty coating, and safe from the action of the atmos- 
pheric air, we can but wonder that its skin escapes as well 
as it does. More than one-third of the cases of eczema 
occurring before the fifth year of life occur in the first year. 
Add to the vulnerability of the skin the overzealous care 



ECZEMA INFANTILE. 195 

commonly bestowed upon it for a few months after birth, 
and we have a good explanation for its frequence. Bad 
diet has much to do with its production. The vast majority 
of the little sufferers are nursed too often if at the breast, 
" every time they cry " being the rule ; or fed too frequently 
or improperly, " everything that is going " being again the 
rule. Inattention to the condition of the diapers is another 
active cause of the eczema about the genitals. Teething is, 
without doubt, an exciting cause, a fresh outbreak of eczema 
marking the eruption of a new tooth. Want of self-control 
in scratching is an aggravating circumstance. The frequent 
disturbances of digestion, so common at this period of life, 
predispose the infant's skin to eczema with rather more 
force than do the same troubles in adults. Fat babies are 
frequent subjects of eczema, especially of the intertriginous 
varieties. 

Treatment. The treatment of eczema infantile is along 
the same lines as that of eczema in adults. Special stress 
must be laid upon the feeding of infants, and strict rules 
must be laid down for the parent's guidance. The condition 
of the breast milk must be inquired into, as it is often of too 
poor quality to nourish the child. Women will sometimes 
nurse their children far too long, with the idea of preventing 
conception. If the child is on the bottle, the quality of the 
milk must be investigated, and it as well as the amount 
regulated. It is also very necessary to insist upon the child 
wearing a mask in eczema of the face and scalp. This may 
be made of light flannel or linen, a piece of the stuff being 
cut somewhat after the shape of the face, with holes cut out 
for the nose, eyes, and mouth. A skull-cap is to be made, 
onto which the mask may be sewed, or pinned with safety- 
pins. The ointment is to be spread upon lint or cheese- 
cloth — a strip for the forehead, one for the chin, and one 
for each cheek. These are to be laid upon the face, and 
then the mask put over them, fastened to the skull cap, 
and tied behind the head by two strings from its lower 
corners. It is astonishing what relief this affords to the 
itching, and how much more rapidly the case improves. 
The itching of the skin may be relieved by appropriate 



196 DISEASES OF THE SKIN. 

dressings, but if not it may become necessary to put the 
child in a home-made straight-jacket, by putting it in a pil- 
low-case and sewing up the same between the arms and 
body. This is an extreme measure and should not be 
lightly adopted. In eczema of the crotch great care must 
be given to changing the napkins as soon as soiled. Fresh, 
clean ones must be put on, not those that have been dried 
without being washed. Dr. George H. Fox has called 
attention to a tight prepuce as the cause of eczema in male 
children. The urine dribbles away, so that a few drops wet 
the clean diapers, and thus keep up the trouble. In such 
cases judicious stretching of the prepuce may obviate the 
necessity for circumcision. Water must be kept from the 
skin in all acute cases. 

Internally, calomel in tablet triturates, one-tenth grain, 
three times a day for three days, will give us good aid in 
many cases, even though the bowels are not constipated. 
Care must be taken not to produce too frequent and loose 
movements of the bowels. Other medication will be neces- 
sary according to the nature of the case. Cod-liver oil 
will often cure a case which has been very obstinate. The 
local treatment is according to the rules already given under 
Eczema. 

Eczema Marginatum. See Trichophytosis. 

Eczema Seborrhoicum. Unna read a paper upon this 
disease in the Dermatological Section of the Ninth Inter- 
national Medical Congress at Washington in 1887, and 
published some papers upon the same subject in foreign 
journals at about the same time. He does not believe that 
there is such a disease as seborrhcea sicca or pityriasis, but 
that both of these, as well as several other recognized forms 
of eczema, are all forms of his seborrhoeal eczema. Among 
several other articles on the subject that of Dr. George T. 
Elliot in Morrow's System of Gf-enito-urinary and Skin Dis- 
eases, vol. iii., stands easily first. It is upon the papers of 
Unna and Elliot that this section is founded. 

Symptoms. Unna teaches that the starting-point of almost 
all cases of seborrhoeal eczema is the scalp ; more rarely the 



ECZEMA SEBORRHOICTJM. 197 

margin of the eyelids, the axillae, bend of the elbows, or 
cruro-scrotal fold. Upon the head it exists mostly as an 
affection that is scarcely noticeable at its onset, and it is 
only after months or years that a sudden increase, loss of 
hair, an unusual amount of scaliness or collection of crusts, 
severe itching, or, finally, a circumscribed moist spot, or an 
evident eczema, leads the patient to consult a physician. 
The hair during the early stage is abnormally dry. A pro- 
gressive alopecia pityrodes may show itself, the scaliness 
decreasing with the loss of the hair to make way for a 
hyperidrosis oleosa. Or the scaling and crusting may in- 
crease, a corona seborrhoica may form along the hair line, 
and the affection may extend upon the temples, over the 
ears to the neck, or on to the nose and cheeks. Or the 
catarrhal symptoms may be pronounced, and a moist eczema 
affect the scalp and ears, and, in children, the cheeks and 
forehead. (It will be readily recognized that his slightest 
form is the usually recognized pityriasis, his more pro- 
nounced form is seborrhoea sicca, and his most pronounced 
form is the seborrhoea with dermatitis.) 

Next to the head, the sternum is a favorite site for the 
eruption, where it most commonly assumes the crusted form, 
and most rarely the moist form. The sternum is affected 
secondarily to the scalp. The crusted form is in round or 
oval spots the size of the finger-nail ; these group and partly 
coalesce, forming patches the size of a silver half-dollar, 
having a scalloped border. The color is yellow, with a 
delicate red border. These may clear up somewhat in the 
centre and form circles, or break and form bow-shaped 
figures with the convexity outward. The lesions of this 
form are usually covered with a greasy crust. The back is 
similarly affected. (This is Duhring's seborrhoea corporis.) 

In the axillae we meet most commonly with the moist 
form, and here it shows a tendency to spread with rapidity 
upon the thorax. From the shoulders it spreads down upon 
the arms almost always in the form of yellowish-red, crusted 
papules, which tend to unite in patches, and also to form 
rings. At times it may look very much like psoriasis. It 
shows a predilection for the flexor surfaces. The backs of 



198 DISEASES OF THE SKIN. 

the hands and fingers are often affected with a moist eczema, 
the trunk and arms escaping. 

Upon the palms and soles we find little heaped-up masses 
of scales corresponding to individual coiled glands and re- 
sembling psoriasis guttata. Later the epidermis peels off, 
but there is never any moisture. The crusted form gener- 
ally appears in ring or serpiginous patches on the trunk, 
buttocks, and hips. The cruro-scrotal fold and the approxi- 
mating surfaces of the thigh and scrotum are favorite loca- 
tions for the disease, probably forming here many of the so- 
called cases of eczema marginatum in its dry form with 
festooned margins to the patches, or as an intertrigo when it 
is more moist. The thigh and extensor surface of the knee 
are but little affected, while the popliteal space and the leg 
often are, either in the large papular or the thick-crusted 
form. 

Upon the bearded portion of the face, when the beard is 
worn, we find either a diffused pityriasis, or circumscribed, 
reddened, itchy patches. Upon the face of women and the 
unbearded portions of the face in men we have circumscribed, 
scaly, yellowish or yellowish-gray, slightly elevated patches, 
mostly on the forehead, cheeks, and naso-labial fold. There 
may also be red papules, free from scales or with fine yellow 
ones, with redness of the skin between the papules. The 
face is the favorite location for a moist seborrheal eczema, 
in children especially. The eyebrows are often involved as 
well as the eyelids. The latter are often swollen, and red, 
and scaly. The vermilion borders of the lips may be affected 
and the lips swell, scale, crust, and perhaps crack. The 
disease may attack both the outer parts of the ear and the 
external auditory canal. Scaliness, itching, and great in- 
crease of cerumen mark the process in the latter situation. 

Etiology. Seborrheal eczema occurs at all ages and in 
both sexes, but it is specially prevalent between puberty and 
thirty years of age. Though most of the patients with it 
seem to be in good health, careful inquiry will bring out the 
fact that they either are not in perfect condition or they are 
living unhygienic lives. Elliot thinks that an indoor life 
favors the disease. Contagion probably plays a considera- 



ECZEMA SEBORRHOICUM. 199 

ble part in causation, and barber shops doubtless are dis- 
tributing centres of the malady. It is quite impossible to 
estimate the prevalence of the disease, as only the more 
pronounced cases are seen by the physician. 

Pathology. According to Elliot, it is a dermatitis of 
catarrhal nature. He found evidences of inflammatory in- 
filtration about the papillary vessels, and the ascending 
branches from the subpapillary plexus, and along the hair 
follicle, even in what is usually regarded as a pityriasis. In 
seborrhcea sicca, so called, the infiltration extended to the 
plexus itself, while in the higher grades the inflammation 
involved nearly the entire cutis. The sebaceous glands were 
apparently unchanged, and there were no evidences of the 
incomplete metamorphosis of their cells, such as is usually 
described in seborrhoea sicca. Contrary to Unna's observa- 
tions, he never found any fat in the sweat glands or their 
ducts, but there were evidences of degeneration of the 
glands ; nor did he find fatty infiltration of the cutis or 
rete. 

Unna has described a mulberry coccus in this disease. 
Dr. Merrill 1 has succeeded in isolating a diplococcus, in 
making a pure culture of it, and in reproducing the disease 
by inoculation. If his observations are corroborated, we 
have the evidence that the disease is parasitic. 

Diagnosis. Many of our cases of eczema are included 
by Unna and Elliot in seborrhoeal eczema or dermatitis, as 
the latter thinks the preferable name. In diagnosis stress 
is laid upon the fact that the disease begins upon the scalp 
and spreads from there downward in a more or less capri- 
cious manner ; upon the more or less absence of itching ; 
upon the superficial character of the lesions, their tendency 
to take on definite forms, their yellowish color, and the greasy 
feeling of the crusts. In all these things the disease differs 
from an eczema. At times seborrhoeal eczema of the body 
bears so striking a likeness to pityriasis rosea that it is hard 
to differentiate the two. The rings of pityriasis rosea are 
not so greasy and yellow, and have fawn- colored, dry cen- 

1 N. Y. Med. Journ., 1895, lxii. 528. 



200 DISEASES 01 THE SKIN. 

tres. Then pityriasis rosea runs a rapid and self-limited 
course, whereas seborrhoeal eczema is chronic. If pityriasis 
rosea occurs typically upon the trunk, there is no difficulty ; 
but when scaly ring-shaped patches occur on the limbs alone 
a positive diagnosis cannot be made without a good deal of 
study. 

The psoriasiform seborrhoeal eczema differs from psoriasis 
in occurring in locations not typical of psoriasis, and in hav- 
ing a more yellowish cast of color, and more greasy, yellowish 
scales. Many cases can be diagnosticated only by taking 
into consideration the probabilities for and against psoriasis. 

Treatment. The best remedy for the moist form is, 
according to Unna, sulphur, and for the scaly and crusted 
forms chrysarobin, pyrogallol, and resorcin. It is always 
necessary to direct special attention to the scalp and eye- 
lids, as these are the foci from which the disease spreads. 
For the disease upon the back of the hand, it is recom- 
mended that the affected parts be covered with a thin layer 
of lint soaked in the following solution diluted one-half: 

Alcohol, dil., 180 " M. 

and over this a large piece of gutta-percha tissue is to be 
bound. This is to be used at night, and during the day it 
is to be kept dressed with a zinc-oxide paste with or without 
tar, sulphur, or resorcin. 

In my hands sulphur in some form answers best in most 
of the cases. Elliot commends for the disease, specially as 
it affects the scalp, lotions of resorcin, 3 to 10 per cent, in 
equal parts of alcohol and water, with which the parts are 
to be moistened several times a day. The scalp is to be 
washed with soap and warm water once or twice a week. If 
the lotion is too drying, a resorcin ointment of the same 
strength is to be used once or twice a week or on alternate 
days. He uses sulphur as an after-treatment. 

Elephantiasis (E 2 l-e 2 -fa 2 nt-i 2 -a'-si 2 s). Synonyms : Bar- 
badoes leg ; Cochin- China leg ; Glandular disease of Barba- 



ELEPHANTIASIS. 



201 



does; Sarcocele of the Egyptians; Tropical big-leg; Buc- 
nemia tropica ; Morbus elephas ; Pachydermia ; Spargosis ; 
Phlegmasia Malabarica ; Hernia carnosa ; Elephantiasis 
Indica seu Arabum. 



Fig. 21, 




Elephantiasis. (After Taylor.) 

A chronic endemic or sporadic disease of the skin, char- 
acterized by hyperplasia of the skin and subcutaneous tis- 
sues, due to a stoppage of the lymphatics, affecting chiefly 
the lower extremities, and marked by enormous enlargement 
of the affected part. 

Symptoms. In certain tropical regions, such as India, 
China, Japan, Egypt, Arabia, the West Indies, and South 
America, the disease is endemic, but sporadic cases occur in 
all parts of the world. The symptoms of the two forms differ 



202 DISEASES OF THE SKIN. 

only in that in the endemic variety there is usually what is 
called " elephantoid fever," with lumbar pain, nausea, and 
vomiting, and followed by sweating. The fever is of high 
grade, and bears a striking resemblance to malarial pyrexia. 
In sporadic cases the characteristic fever is wanting, though 
usually there is some constitutional disturbance preceding 
the local symptoms. In other instances the fever is alto- 
gether wanting. 

Locally the affected part at first is attacked apparently 
by erysipelas, or a deep dermatitis, phlebitis, or lymphan- 
gitis ; it becomes greatly reddened and swollen ; and there 
may or may not be a clear or milky discharge from the 
skin, and an eruption of vesicles. After a time these symp- 
toms subside, but the part does not return to its normal 
size, and there is some pitting of the skin on pressure. After 
a few months there is a repetition of the attack, and the 
part is left still more enlarged. And so the case progresses 
with varying periods of quiescence, and recurrent erysipe- 
latous attacks, each one leaving the part more thickened 
than before, until it attains enormous proportions. The 
normal contour of the part is lost ; the folds of the skin 
are obliterated, the surface is smooth and shiny, and the 
color grows darker, even blackish. Now no impression can 
be made upon the swelling by pressure of the finger. Ul- 
cerations are apt to occur, and some cases show varicose 
lymphatics which are tender and painful, and may rupture 
of themselves or by accident and discharge a clear or milky 
chylous, coagulable fluid. The escape of this fluid saps the 
patient's strength. 

The parts most frequently affected are the legs, usually 
one, but may be both ; and next to them, the male or female 
genitals. It occurs also on the arms, face, ears, female 
breast, and tongue. When the leg is the seat of the disease 
it becomes so large as to interfere with locomotion and com- 
pel the sufferer to take to his bed. The surface of the limb 
may be smooth ; or uneven on account of the varicose lym- 
phatics ; or warty on account of enlargement of the papillae. 
The foot and leg may melt into each other, as it were, all 
trace of an ankle being lost. Wherever there are two sur- 



ELEPHANTIASIS. 203 

faces in contact there is apt to be a decomposition of the 
sweat, sebaceous matter, and epithelium, giving rise to a 
foul odor like, but worse than, that of an ordinary inter- 
trigo. The lymphatic glands in the groin are enlarged. 
Eczema may develop with its attendant itching. The ap- 
pearance of this elephantine leg gave the name to the dis- 
ease. When the scrotum is the affected part, vomiting 
often occurs in the febrile attacks, as well as pain in the 
groins, along the spermatic cord, and in the testicles. 
Hydrocele may develop, and the abdominal rings, over- 
stretched by the swollen cords, may give opportunity to 
the formation of hernia upon the subsidence of the acute 
symptoms. The scrotum may become so large as to reach 
the ground when the patient is standing, and one case has 
been reported in which it weighed one hundred and ten 
pounds. One form of the affection is called " lymph scro- 
tum or naevoid elephantiasis/' on account of the marked 
dilatation of the lymphatics. 

There are all degrees of thickening of the skin and sub- 
cutaneous tissues, but the recurrent attacks of erysipelas 
and the progressive enlargement are characteristic of all. 
The bones may become enlarged. This is a very rare 
affection, which is called " acromegalia." In the Lancet of 
June 11, 1887, several cases are reported, one of which 
was on exhibition in a travelling show as the " Elephant 
man." In his case the head attained massive proportions. 

Etiology. The disease occurs in both sexes and in all 
ages, but is most common in men of middle life and in the 
dark-skinned races. Moncorvo 1 reports a case in an infant 
four months old, and speaks of a case in one fifteen days 
old. He believes that it may develop in utero. Floras 2 
reports a case beginning at birth and remaining stationary 
for fifteen years, when it took on the typical course of the 
disease. It is particularly prevalent in damp, malarious 
parts of the seacoast. It is not supposed to be hereditary, 
though in countries in which it is endemic several members 

1 Kev. mens, des Mai. de l'Enfance, 1886, iv. 101. 

2 ArchiY klin. Chirurgie, 1888, xxxvii. 598. 



204 DISEASES OF THE SKIN. 

of the same family may be affected by it. Leprosy and 
elephantiasis have been accidentally associated. Exposure 
to cold, phlegmasia dolens, cellulitis, ulcers, lupus, repeated 
attacks of eczema or erysipelas, posture, as the hanging 
down of a limb on account of rheumatism, may give rise 
to the disease. In fact, any disease of the skin that is at- 
tended by repeated inflammatory outbreaks favors the occur- 
rence of elephantiasis. The filaria sanguinis hominis is 
said to be the cause of the endemic form of the disease. 
It is not found in every case, and is rarely encountered in 
sporadic cases. 

Pathology. Anything that will occlude the lymphatic 
channels may cause the disease. In endemic cases it is the 
ova of the filaria that do this. In sporadic cases the several 
etiological factors play the same part. However caused, 
the result is an enormous hypertrophy of the subcutaneous 
tissue from increase of fibrinous tissue in various stages 
of development. The corium is also increased in thickness 
and there is proliferation of the epidermis, enlargement 
of bloodvessels, lymphatics, and nerves. In advanced cases 
the muscles undergo fibro-fatty changes, and the bones be- 
come enlarged (Crocker). 

Diagnosis. The recognition of elephantiasis is easy, as 
its symptoms are pronounced. In some cases of syphilis, 
however, an elephantiasic thickening of the foot or feet 
takes place that may be thought to be elephantiasis. In it, 
however, there is an absence of the history of repeated 
inflammatory attacks, the outline of the thickening is rather 
well defined, and old cicatrices or ulcers characteristic of 
syphilis will commonly be found. The condition is one of 
gummatous infiltration with chronic oedema, consequent 
upon obstruction of the lymphatics. 

Treatment. The best thing for a patient with endemic 
elephantiasis to do is to go to a more healthful climate. The 
treatment of the patient during the exacerbations is purely 
symptomatic, with fomentations, quinine, iron, and the like. 
Various measures for the cure of the disease have been pro- 
posed, but none is perfectly satisfactory. Of course, the 
scrotal tumor may be cut off. The leg has been amputated 



EMPHYSEMA OF THE SKIN. 205 

at the hip, a dangerous operation. Unfortunately the other 
leg has become diseased soon after the one has been cut off. 
Ligature of the femoral artery has been performed, but the 
result has not been satisfactory. Compression by means of 
a Martin's rubber bandage, or the ordinary roller bandage, 
will afford relief. When it is left off for a time enlargement 
will again take place. It, of course, cannot be used while 
inflammation is present. Bentley 1 has reported the cure 
of a case by the inunction of a half-drachm of mercurial 
ointment twice daily, and the application of a firm bandage 
for fourteen days. After that the inunctions were made 
once a day. Internally he gave iodide of potash alone, or 
in this formula : 



^. Potass, iodid. , ^ij ; ] 

Potass, chlor. , 3j ; 1 

Sol. hydrarg. perchlor , ,^ss; 6 

Inf. chiretta, ad % viij ; 100 

Sig. % ss three times a day. 



M. 



Galvanism has produced alleviation, if not cure, in some 
cases. Hardaway has seen great amelioration in one case 
by the use of Squire's glycerole of the subacetate of lead. 
Massage is beneficial. 

Prognosis. Unless exhausted by the loss of lymph the 
disease may last indefinitely without deterioration of the 
health. Death may result from pyaemia or thrombosis. 
The patient often dies from some intercurrent affection. 

Elephantiasis Grecorum. See Leprosy. 

Emphysema of the skin is a rare accident. It usually 
affects the upper chest and neck, and is due to a rupture of 
the pulmonary alveoli on account of vomiting or paroxysmal 
coughing, and the air making its way under the skin. The 
affected part looks swollen, feels cushiony, and gives a 
delicate crackling sound on palpation. There will be a 
history of the sudden occurrence of the swelling after cough- 
ing or vomiting, and probably more or less dyspnoea will be 
experienced. The air slowly escapes, and the parts return 
to their normal condition. 

1 Lancet, 1878, i. 785, 
10 



206 DISEASES OF THE SKIN. 

Endemic Verrugas. See Favus. 

Endothelcarcinoma. See Carcinoma. 

Endurcissement du Tissu Cellulaire. See Sclerema 
neonatorum. 

Engelures. See Dermatitis calorica. 

Ephelides. See Lentigo. 

Ephidrosis. See Hyperidrosis. 

Ephidrosis Cruenta. See Haematidrosis. 

Ephidrosis Tincta. See Chromidrosis. 

Epidemic Skin Disease of Savill. See Dermatitis 
Epidemica. 

Epidermolysis (E 2 p-i 2 du 5 rm-o 2 l r -i 2 si 2 s). Synonyms: Acan- 
tholysis bullosa (Groldscheider and Joseph) ; Dermatitis 
bullosa (Valentine). This is a rare disease, or rather pecu- 
liarity of the skin, in which bulla arise upon the slightest 
pressure. The disease shows itself in infancy, and occurs 
especially upon the hands and feet, but may occur anywhere 
on the body. The tendency to the formation of bullae les- 
sens toward middle life. The lesions begin either as a 
red spot, which is itchy, or without precedent redness or 
other subjective symptoms. The bulla begins to form 
shortly after the exciting pressure has been received, and 
keeps on enlarging for two or three days. It then gradu- 
ally decreases, dries into a crust, which falls, leaving healthy 
skin. If the bulla is broken, it discharges a yellow, slightly 
sticky fluid, and leaves a suppurating base. The disease is he- 
reditary in certain families, but it may occur independently 
of this. It is most pronounced in summer-time. In most 
cases hyperidrosis is pronounced. Elliott, 1 from his micro- 
scopical study of the disease, believes it to be " due in a pre- 
disposed individual to an excessive response on the part of 
the bloodvessels to an external irritation, and the consequent 
pouring out of an enormous amount of serous exudation." He 

1 Journ. Cut. and Gen.-Urin. I>is., 1895, xiii. p. 10. 



EPITHELIOMA. 207 

regards it as " an inflammatory process, originating in the 
cutis itself, and manifesting itself by the formation of bullae 
after slight or severe traumatisms." 

Epithelialkrebs. See Epithelioma. 

Epithelioxn Kystique Benin. See Adenoma of sweat 
glands. 

Epithelioma (E 2 p-i 2 -thel-i 2 -o'ma 3 ). Synonyms : (Fr.) 
Epitheliome cancro'ide; (Ger.) Epithelialkrebs ; Cancroid, 
Skin cancer, Epithelial cancer, Noli me tangere. 

Epithelioma is a chronic, progressive, malignant new 
growth in the skin or mucous membrane, which is char- 
acterized by the formation of ulcers with raised, hard waxy 
edges, and by a strong tendency to return after apparent 
removal by knife or caustic, 

Symptoms. Epithelioma always begins in a most inno- 
cent manner, and may be present for months or years be- 

FlG. 22. 




Epithelioma. 
(From Prof. G. H. Fox's service at the Vanderbilt clinic.) 

fore the patient dreams that he has a serious disease. It 
may occur upon the skin alone, or upon the mucous mem- 
brane alone, or upon both the skin and mucous membrane 
at their line of juncture. Epitheliomas occurring upon the 
tongue, larynx, or uterus do not concern us here, as they 
belong to the domain of surgery. The starting-point of the 



208 DISEASES OF THE SKIN. 

disease may be a crack or an abraded scaly spot, as on the 
lip ; a small, flat, scaly, sebaceous patch ; a white, pearly 
looking, hard nodule ; a senile or other wart or papilloma ; 
a pigmentary mole ; a cicatrix ; an adenoma ; a chronic or 
lupous ulcer ; a psoriatic patch, or some other new growth in 
the skin. Some of these lesions may have been present for 
many years, as, for instance, a mole. Some appear but a 
short time before they frankly declare their nature, such as 
the waxy nodule. However it may begin, after a varying 
time ulceration occurs, the disease spreads at its edges, and 
the ulceration grows deeper and deeper, eating its way 
through skin, muscles, and bone in the infiltrating form, or 
creeping over the surface in the most superficial form. The 
lymphatic glands may be involved early in the course of the 
disease, or not for many years. Eventually they become 
swollen, hard, break down, and ulcerate, assuming the ap- 
pearance of an epitheliomatous ulcer. A typical epitheli- 
omatous ulcer is irregular in shape, with raised, hard, waxy- 
looking, rounded, or everted edges, over which, quite com- 
monly, course dilated bloodvessels; the floor is uneven, 
bleeds easily when touched, and is covered by a brownish 
crust, or a sanious, purulent secretion. Epitheliomas are 
usually single lesions, but they may be multiple. Some 
years ago there was a patient in Dr. George H. Fox's ser- 
vice at the New York Skin and Cancer Hospital who had 
scores of epitheliomas developing from large, waxy, reddish 
nodules scattered all over his face. Sometimes a single epi- 
thelioma attains vast dimensions, involving the whole of one 
side of the face, scalp, and neck in one huge excavated ulcer. 
Sometimes before the characteristic ulceration develops the 
new growth may take the form of a single enlarged papilla, 
or a group of them. In some cases it may have a cauli- 
flower-like appearance, spreading out from a more or less 
narrow base. Fissures are apt to form between the papillae, 
and then there is usually an oifensive discharge. This is 
called the papillary form. The most typical case of the 
cauliflower-form that I have seen was on the vulva. 

Subjective symptoms are absent in many cases at first, 
but in the deep, infiltrating form pain of a lancinating char- 



EPITHEL TO MA . 209 

acter is present. This often is so severe that the sufferer is 
robbed of his sleep. Sometimes there is no pain, and the 
patient experiences only the discomfort incident to the 
ulceration. Sooner or later in nearly all cases lancinating 
pain is a symptom of the disease. 

The course of the disease is always chronic. Different 
cases show different degrees of malignancy. Some will 
prove fatal in four years or less ; some will last indefinitely. 
There is no tendency to recovery, though at times a partial 
attempt at healing will be made. I have watched one super- 
ficial epithelioma in an old Irishwoman, in Prof. E. B. 
Bronson's service at the New York Polyclinic, creep over 
the skin of the face, healing up in the older parts while 
spreading ahead. She refused active interference. While 
all epitheliomas show a strong tendency to return after 
operation and in the scar left by it, in some cases this ten- 
dency is much more marked than in others. 

While epithelioma may occur upon any part of the body, 
it is more frequently located upon the lower lip, where it 
occurs, according to Paget, in 50 per cent, of the cases. 
The next most common location is the face. The external 
genital organs of both sexes, and the anal region more 
rarely, are other common sites. The upper lip is very 
rarely affected. A favorite location upon the face is upon 
the side of the nose and near the inner canthus of the eye. 
Here it is very apt to pass over onto the eyelids, and 
destroy them. Not infrequently it begins upon the eyelid 
itself. 

It is customary to describe a number of forms of epithe- 
lioma, but it seems to me much better, especially for a 
student, not to encumber his mind with too many names. 
The superficial, deep-seated or infiltrated, and the papillary 
forms have already been mentioned. The chimney-sweep 's 
cancer is an epithelioma of the scrotum, met with in par- 
affin-workers and chimney-sweeps. The rodent ulcer used 
to be described as a special form of disease, but it is now 
considered to be an epithelioma. Clinically, it is supposed 
to be characterized by occurring on the skin of the upper 
half of the face, by running a slow and painless course, by 



210 DISEASES OF THE SKW 

not involving the lymphatics, and by perpendicular rather 
than lateral extension. 

Etiology. The cause of epithelioma is often obscure. 
We know that repeated irritation of a part is often followed 
by its advent. Smoking short clay pipes is not uncom- 
monly followed by epithelioma of the lip ; a ragged tooth 
accounts for many an epithelioma of the tongue ; the wear- 
ing of spectacles or eye-glasses has in some cases apparently 
caused the new growth upon the nose ; constant picking or 
inadequate attempts at the removal of warts and scaly spots 
would seem to account for epithelioma of the face ; and the 
scratching to relieve the pruritus of the anus may play the 
same part in producing the disease about the anus. This 
constant irritation would explain the appearance of epi- 
thelioma in paraffin-workers and chimney-sweeps, in chronic 
ulcers, psoriasis, old cicatrices, and the like. A congenital 
or acquired phimosis and the repeated inflammation due to 
decomposing smegma are the forerunners of the disease 
upon the penis. Age is the most pronounced predisposing 
cause. The disease is rare under thirty years of age, and 
increases in frequency beyond that period. Heredity has 
some influence, though Lewis has found that it is not so 
well marked as it is frequently assumed to be. Males are 
more often affected than females. It seems to have a pre- 
dilection for all neoplastic growths. The theory of Darier 
and Wickham is that it is parasitic and due to psorosperms. 
This is still unproved. It is surmised by some that it is 
contagious. It is true that there is some evidence both of 
this and its endemic nature. 

Pathology. Crocker sums up the pathology of the 
affection as follows : " The essence of the epitheliomatous 
process is the development of epithelium and its infiltration 
into the deeper tissues where it does not normally exist, and 
where its presence produces irritation and consequent in- 
flammatory changes." " Cell-nests, consisting of horny 
transformed cells in the centre, and of laminae of flattened 
epithelium externally, are characteristic of the disease, but 
are not present in every case, nor is their presence always 
necessary for a diagnosis." (Robinson.) 



EPITHELIOMA. 211 

Diagnosis. The disease must be differentiated from 
lupus, syphilis, papilloma, and seborrhocal warts. From 
lupus it differs in an entire absence of brownish lupus 
tubercles ; in beginning late in life, as a rule, while lupus 
begins in early life ; by its comparatively more rapid course; 
its lancinating pain ; the involvement of the lymphatic 
glands ; the deep ulceration ; the waxy, raised, hard margin ; 
and the development of the cancerous cachexia. From 
syphilis it differs in having a single and not a multiple 
lesion ; in its slower course ; in its showing no tendency to 
recovery; in its not responding to internal treatment; in 
its painfulness ; and in its waxy, raised, hard margin. An 
initial lesion of syphilis on the lip has not infrequently been 
taken for an epithelioma. In it we have more rapid growth, 
more induration, an early enlargement of the neighboring 
lymphatic glands of peculiar hardness, and the appearance 
of secondary eruptions on the body, all of which are want- 
ing in an epithelioma. From papilloma and seborrheal warts 
there are no positive diagnostic marks of distinction. Either 
of the two diseases appearing late in life or showing symp- 
toms of activity at that time should rouse our suspicions. 

Teeatmbnt. Complete and radical destruction of the 
disease is the only thing to be done in the treatment of 
epithelioma. As a prophylactic measure it is well to de- 
stroy all suspicious warts appearing after middle life, and 
to apply appropriate treatment to seborrhoeal patches occur- 
ring at the same period. Superficial caustics should never 
be used to an epithelioma, as they only encourage its 
growth. The radical treatment will differ with the point of 
view, all surgeons inclining to the knife, while dermatolo- 
gists advocate the curette or powerfully destructive caustics. 
If the knife is used, it must cut out a wide margin beyond 
the growth. Extirpation is especially applicable, and the 
most appropriate treatment of epithelioma of the lip, eye- 
lid, and penis. In the latter the organ must be amputated 
above the ulcer, if that has attained any size, and the in- 
guinal glands likewise taken out. In all cases in which 
the lymphatic glands have become involved they should be 
taken out. 



212 



DISEASES OF THE SKIN. 



To all superficial epitheliomas and to many of the in- 
filtrating variety Schwimmer's plan of treatment will be 
applicable, and will prove curative. The growth is to be 
scraped out thoroughly with the dermal curette (Fig. 23) ; 
the diseased tissues will give way readily ; the bleeding is 
to be stopped by pressure ; and a pyrogallic acid ointment 
of 33J per cent, strength is to be applied. Care should be 
taken that it be applied exactly to the growth, for though 
it exerts its greatest action upon the diseased tissues, it also 
acts upon the sound skin. This ointment will produce a black 
crust over the growth, on account of oxidation of the acid, and 
will cause a free discharge from the scraped surface during 
a few days. The discharge becomes less by degrees. After 
a week or ten days the black crust is to be removed by 



Fig. 23. 




The dermal curette. 



covering it with carbolized vaseline for twenty-four or forty- 
eight hours. Last of all mercurial plaster is to be applied, 
under which the part will heal. This method gives most 
satisfactory results, and is not particularly painful if cocaine 
is used hypodermically before the scraping. Smaller epi- 
theliomata can be curetted without using cocaine. 

Arsenic holds the first place among caustics. Marsden's 
paste, composed of equal parts of arsenious acid and gum 
acacia rubbed together and mixed into a paste with water 
just before using, is perhaps the most often used. It is 
dreadfully painful and often causes great oedema. It should 
be applied accurately to the affected part on linen, and left 
on for twelve to twenty-four hours, according to the patient's 
endurance. Poultices are to be applied after the paste, and 
kept on continuously till the slough separates. If the 



EPITHELIOMA. 213 

growth has not been destroyed, the process may be re- 
peated. Lewis 1 has had good results from using Bougard's 
paste, as follows : 

R. Wheat flour, j „ 60 



Starch 

Arsenic, 1 

Cinnabar, \ aa 5 

feal. ammoniac, J 

Corrosive sublimate, 

Solution chloride of zinc @ 52°, 245 



50 

M. 



The first six ingredients are separately ground to a fine 
powder and mixed in a mortar. Then the solution of the 
zinc is slowly added while the mass is stirred. It is to be 
kept covered in an earthen jar. A portion is to be applied 
accurately to the part and kept on for thirty hours, and 
followed by a poultice. Lactic acid is another powerful 
caustic, to be applied by mixing it with an equal part of 
finely powdered silica and spreading it upon gum-paper. It 
is kept on for twelve hours and renewed twenty-four hours 
afterward. Hardaway prefers to apply the syrupy acid by 
means of absorbent cotton for ten or fifteen minutes, and 
then wash off the excess of acid with water. This is done 
daily. 

The thermo- or galvano-cautery may also be used. Re- 
sorcin has its advocates, as has caustic potash, chloride of 
zinc, and the nitrate of silver. These may be of service 
where, for any reason, a more radical operation is not ad- 
missible. Fuchsin and methyl-blue, either injected under 
the skin or locally applied, will sometimes seem to stay the 
progress of an epithelioma, but will not cure it. 

There are some cases that are too advanced for any ac- 
tive interference, and then palliative remedies only are 
permissible. 

Prognosis. The prognosis of epithelioma as to life is 
fairly good. While, as already said, there are some cases 
that are rapidly fatal, many do not seem to have any effect 
on the patient's health for years. The prognosis as to cure 
is always doubtful. Some cases, whether excised or destroyed 

1 Journ. Cutan. and Gen -urin. Dis., 1890, viii. 70. 

10* 



214 DISEASES OF THE SKIN. 

by other means, will return after a time. If they do return, 
they must be destroyed again. 

Epithelioma Contagiosum. See Molluscum. 

Epithelioma, Multiple Benign Cystic. Under this title 
Fordyce places 1 those cases formerly described under the 
names of hydradenomes eruptifs, syringo-cystad6nome, epi- 
thelioma adenoides cysticum, and others, and reports two 
additional cases. It is characterized by the eruption of 
small, pale-yellow, pearly, or pinkish tumors from pin-head 
to pea-size, that are located on the face, chest, back, and 
upper extremities. They are firm to the touch, and pain- 
less. Some of the tumors are tense, shiny, freely movable, 
sometimes with a central depression. Some are translucent, 
like vesicles, some look more like milia. They slowly en- 
large to the size of a pea and then remain stationary. The 
disease has no eifect on the general health. In some cases 
it seems to be hereditary. 

Microscopic examination shows the tumors to be made up 
of irregular masses and tracts of epithelial cells, and " cell- 
nests." Colloid degeneration of individual cells is also seen 
in the cell-masses. There is also a down growth and pro- 
liferation of the epidermis and external root-sheath of the 
hair follicle. It is supposed that the growths are due to 
misplaced epithelial cells of indifferent nature. (Fordyce.) 
Their treatment is by curetting. 

Epitheliomatose Pigmentaire. See Atrophoderma pig- 
mentosum. 

Equinia (E 2 k-wiV-i 2 -a 3 ). Synonyms : Glanders ; Farcy ; 
Malleus; (Fr.) Morve ; (Ger.) Rotz. 

A contagious, specific disease, with general and local 
symptoms, derived from the horse, ass, or mule. 

This is a rare disease in the human race, and runs an 
acute, subacute, or chronic course. It is derived by inocu- 
lation with the bacillus mallei, and its symptoms show them- 
selves in from three days to six weeks afterward. Its consti- 
tutional symptoms are fever, prostration, constipation, and 

1 Journ. Cutan. and Gen.-urin. Dis., 1892, x. p. 459. 



ERYSIPELAS. 215 

rheumatic pains, with the subsequent development of a 
typhoid condition in which the patient dies. The objec- 
tive symptoms are a profuse purulent or sanious nasal dis- 
charge ; chancroidal ulceration at the site of entrance of the 
poison ; phlegmonous inflammation of the affected part ; 
adenitis ; and a cutaneous efflorescence. The latter is a 
disseminated eruption of red macules, which develop into 
yellow papules, upon which variola-like pustules and bullae 
may form. These may coalesce into superficial ulcerations 
and gangrenous patches. Infiltration of the subcutaneous 
tissues may occur and deep sloughs may form. There may 
be a general adenitis, and the glands may break down and 
form ulcerating cavities. The whole skin may be involved 
in these destructive processes. 

Treatment is usually unavailing, and is on general prin- 
ciples. The prognosis is bad. The more acute the symp- 
toms the worse the outlook. 

Erbgrind. See Favus. 

Erysipelas (E 2 r-i 2 -si 2 p'e 2 l-a 2 s). Synonyms : (Fr.) La rose, 
Feu sacre* ; (Ger.) Rothlauf, Rose, Hautrose, Wundrose ; 
(It.) Risipola; St. Anthony's fire, Wildfire, Rose. 

An inflammatory disease of the skin or the adjacent 
mucous membranes, attended always with redness and swell- 
ing, and often with vesicles, bullae, pustules, diffuse sup- 
puration, and gangrene ; and characterized by a tendency 
to spread at the periphery and by fever. (Foster.) 

Symptoms. Though the most modern pathology teaches 
that erysipelas always originates in or about a lesion of the 
skin or mucous membrane, and is therefore allied if not 
identical with the same disease as met with in surgical and 
lying-in wards, so-called surgical erysipelas will not be con- 
sidered here. The outbreak of the disease is usually pre- 
ceded for a day or so with malaise, and the attack is often 
ushered in with a chill, pyrexia, and vomiting. The fever 
is present throughout the whole course of the disease, ex- 
cepting in the most mild type, when it may soon subside. 
The thermometric range is from 101° to 105.5° F. There 
will be other signs of constitutional disturbance, such as a 



216 DISEASES OF THE SKIN. 

coated tongue, a quickened pulse, either full, soft, and com- 
pressible, or, in bad cases, small and weak ; headache, 
drowsiness, or, in bad cases, delirium ; and sometimes albu- 
min is found in the urine. 

The most frequent location of the disease, so far as we 
now are concerned, is the head and face, though it may 
occur anywhere on the body. The eruption begins usually 
as a single patch, which is at once rosy red, swollen, sharply 
defined, irregularly shaped, hot to the touch, and, at first, 
with a smooth glazed surface. The redness may be removed 
by pressure, leaving a yellow stain, but promptly returns 
when the pressure is removed. The patch enlarges, creep- 
ing with more or less rapidity over the surface, always pre- 
serving its sharp, ofttimes indented border that is raised 
toward the sound skin ; it becomes of a darker hue, some- 
times livid ; and very commonly, though not uniformly, 
vesicles or even blebs form on it. These latter may become 
purulent, and breaking, discharge their contents upon the 
surface, which dries into crusts. As the process extends, 
the central portion becomes flattened and less red. Some- 
times new patches may appear, and coalesce with the 
original patch. Sometimes, while spreading peripherally, 
there may be a recrudescence in the older parts. The area 
of the disease may be limited or may include the whole 
body. Very often it seems to be checked by the line of 
the hair, whether of the whiskers or scalp. Not uncom- 
monly it invades the hairy parts, involving one-half or the 
whole of the scalp and extending down upon the neck. 
Then the patient's appearance is indeed deplorable. His 
lips are swollen and livid, his eyelids are swollen so that the 
eyes cannot be opened, and his head seems enormously en- 
larged. At times there may be a lighting up of the disease 
on a distant part of the body, as on the arm with erysipelas 
of the face. The lymphatics and the lymphatic glands are 
involved. The former often show themselves as red streaks. 
The glands may suppurate, and gangrene of the skin may 
declare itself. All grades of inflammation may be reached. 
Sometimes the disease is but slight, sometimes very severe, 
the constitutional symptoms keeping pace with the severity 



ERYSIPELAS. 217 

of the local symptoms. The duration of the disease may be 
six or seven days, or two or three weeks. The patient is 
always more or less prostrated by it, though many of the 
cases we see are ambulant cases. 

The subjective symptoms are burning, tingling, itching, 
and tension. The parts are often tender, and may be spon- 
taneously painful. 

The disease quite commonly begins about the nose, and 
may invade the mouth. Occasionally it spreads rapidly 
over the surface as an advancing, broad, rosy red, raised 
line. Sometimes recurrent attacks occur at short intervals ; 
generally the disease does not recur. When the scalp is 
invaded, the hair commonly falls during convalescence. 
Sometimes some lesion of the skin may be found as the 
starting-point of the inflammation, or perhaps some lesion 
of the mucous membrane of the nose, mouth, or ear. In 
the recurrent attacks the nose is quite commonly the pec- 
cant member. But in a very large proportion of cases no 
lesion at all will be discoverable. When the disease sub- 
sides the skin desquamates, and returns at last to the 
normal condition. 

Erysipelas occurring upon the trunk or extremities pre- 
sents pretty much the same symptoms as when occurring 
upon the face. 

Etiology. It is now generally accepted that the disease 
is infectious, and caused by a specific microorganism that 
was described by Fehleisen. 1 This gains access to the body 
through some lesion of continuity of the skin, however 
minute that may be. As in many of the bacterial diseases, 
so in this one, it is probable that the patient must be in the 
proper condition of health, or rather ill-health, for the lodge- 
ment of the cocci. One attack predisposes to another attack. 
It is more frequent in women than in men ; and in winter 
than in summer. Intemperance, Bright's disease, parturi- 
tion, and a lowered state of nutrition predispose to it. While 
the contagiousness of surgical erysipelas is well known, and 
commonly observed, it is rare to meet a case of facial ery- 

1 Deutsche Zeitschrift fur Chirurgie, 1882, xvi. 391. 



2 J 8 DISEASES OF THE SKIN. 

sipelas traceable directly to contagion. The possibility of 
the occurrence of the disease without infection by the micro- 
organism is still entertained. It has been thought to arise 
from taking cold or to begin in some circumscribed puru- 
lent deposit. 

There is nothing specific about the pathological anatomy 
of the disease. 

Diagnosis. If the clinical features of the disease are 
kept in mind, the sharply defined, swollen, red patch ad- 
vancing with more or less steadiness over the surface, the 
process being preceded by a chill and accompanied by 
marked constitutional disturbance, there is little danger of 
mistaking it. It may, however, be mistaken for an acute 
erythematous eczema, an erythema, or so-called giant urti- 
caria. In eczema the parts are not so swollen ; the margin of 
the patch fades into the surrounding skin ; the color is not so 
brilliant ; the surface is rougher and more scaly ; there is 
decided itching and a lack of constitutional disturbance of 
any magnitude. Erythema lacks the constitutional symp- 
toms of erysipelas ; the redness fades completely away under 
pressure, without leaving a yellowish stain, and springs 
back promptly when the pressure is removed ; it does not 
creep over the skin ; and it is of short duration. In urti- 
caria there will usually be well-marked wheals or a history of 
them ; great itching ; no tenderness ; a short course ; a 
history or evidence of digestive disorders, and an absence of 
marked constitutional disturbance. 

Tkbatment. The great variety of remedies that have 
been vaunted for the cure of erysipelas evidences the fact 
that most cases recover of themselves. There are not a few 
competent observers who are skeptical of the real efficacy of 
any treatment. As the disease tends to lower the vitality 
of the patient we should strive to support his strength by a 
most nutritious diet, and by alcoholic stimulants in adynamic 
cases. The internal medication will be symptomatic to a 
large extent, by means of aconite, quinine, antipyrine, phen- 
acetin, and the like. The tincture of the chloride of iron, 
in twenty to sixty minim doses every two or three hours, is 
regarded by many as a specific, and should be given in all 



ERYSIPELAS. 219 

but the slightest cases. Jaborandi by the mouth, or pilo- 
carpine, one-sixth to one-quarter grain hypodermically, 
have their advocates, but must not be thought of in debili- 
tated subjects. 

The local treatment is very important. If there is a 
wound present, it should of course be thoroughly disin- 
fected on surgical principles. The lead and opium wash is 
an old remedy, and has proved useful in very many cases. It 
is composed of 

R. Liq. plumbi subacetat. dil., £j-iij ; 
Tinct. opii, ^ij-iv; 

Aquse, ad Oj. M. 

It may be used hot or cold, whichever is most agreeable to 
the patient. Dry heat will also relieve the discomfort of the 
patient. Resorcin in watery solution of 2 or 3 per cent, 
strength seems at times to cut short the disease. Duck- 
worth 1 commends chalk ointment made of equal parts of 
melted lard and chalk, with or without a half-drachm of pure 
carbolic acid to the ounce. This is to be smeared on thickly 
and covered with plain or boric lint. White-lead paint has 
done well in some hands. White 2 expects to cure his cases 
of ordinary facial erysipelas by keeping the part constantly 
covered with cloths saturated in the following : 



R . Ac. carbolici, 5 j ; 4 

Akohol. | && 0ss; 250 



M. 



It may be used every alternate hour. Carbolic acid may 
also be used in oil, 10 per cent, strength, and rubbed in 
every hour. Piffard recommends the external use of: 

R . Tinct. belladonna?, 1 part. 

Glycerini, 1 " 

Aquse, 8 parts. M. 

Shoemaker is fond of the ointment of the oleate of bis- 
muth. Ichthyol seems to exert a most happy curative effect, 
and may be used in 15 to 25 per cent, strength as an oil, 

1 Practitioner, January, 1887. 

2 Trans Amer. Derm. Assoc, 1890, p. 42. 



220 DISEASES OF THE SKIN. 

aqueous solution, an ointment with vaseline, or paint. The 
parts should be constantly covered with it. 

The treatment by scarifications about the patch, the in- 
cisions being made diagonally, partly in the sound and partly 
in the diseased skin, and then covered with gauze wet with 
a solution of bichloride of mercury, 1 in 1000, has of late 
been highly praised by many men. This is known as the 
Kraske-Riedel method, and should be always thought of in 
grave cases. Woelfler 1 recommends compression of the 
border-line by adhesive-plaster strips, the disease seldom 
spreading beyond the constricting band. This is specially 
applicable to erysipelas of the limbs. 

Prognosis. Many cases of erysipelas recover of them- 
selves in a few days, while others may run a course of 
weeks. The prognosis may be said to be good in most cases ; 
but even in those that begin as mild ones we should be on 
the watch for grave symptoms. When the scalp is affected 
the prognosis is more grave than when the face alone is the 
seat of the disease. When the patient is the subject of 
chronic alcoholism, or Bright's disease, or is "in the puer- 
peral state, the prognosis is bad. 

Erysipeloid is a term employed by Rosenbach to desig- 
nate an erysipelatoid eruption unattended by constitutional 
symptoms. It is also called chronic erysipelas and erythema 
migrans. It is an infectious disease originating in a wound 
from contact with some dead, putrefying animal substance, 
and chiefly aifecting cooks, butchers, fishmongers, and the 
like. It occurs mostly on the fingers, and spreads from the 
point of inoculation as a dark-red, often livid swelling with 
a sharp border. As it travels over the surface the central 
portion undergoes involution, and thus circles or scalloped 
patches may be formed. It stops spontaneously after one to 
six weeks' duration. There is marked itching or burning 
during the whole course of the disease. It is distinguished 
from true erysipelas by the mildness of its symptoms. A 
salicylic acid or other antiseptic ointment may be used in 
treatment. 

1 Wiener klin. Wochenschr , 1889, Nos. 23 and 25. 



ERYTHEMA HYPERjEMICUM. 221 

» 

Erythanthema (E 2 r-i 2 -tha 2 n r the 2 ma 3 ) is a term employed 
by Auspitz to designate a class of cutaneous efflorescences 
which have in common a basis of erythema. (Foster.) 

Erythema (E 2 r-i-t 2 he r ma 3 ). Synonyms : Dermatitis ery- 
thematosa, Erysipelas suftusum ; (Fr.) Erytheme, Dartre 
e>ythemoide ; (Ger.) Erythem, Hautrothe ; Rose rash. 

An inflammatory hyperemia of the skin attended with 
redness of the surface, and usually only slight or impercep- 
tible exudation, and with little or no disturbance of the epi- 
dermis. (Foster.) 

There are many forms of erythema, but they may all be 
classed under one of two main varieties, namely : Erythema 
hypersemicum and Erythema exudativum. I shall follow 
Crocker's classification, as it is a practical one. It is a ques- 
tion whether erythema should be regarded as a disease or a 
symptom. 

f E. simplex. 

f 1 Dnp to P5rtprnal ' E P ernio - 

■ nal 1 E. intertrigo. 



causes 



| E. iseve. 



f E. hypenemicum \ I K Paratrimina. 



i *■ 



E. fugax. 
Due to internal I E. urticans. 



Erythema < { causes ] E. roseola. 

[ E. scarlatiniforme. 
E. multiforme 



F Pxndativiim J E. seii Herpes iris 
L iL. exuaativum -i R nodosum 

[ E. gangrenosum 

Erythema Hyper^imicum. 

This form of erythema is characterized by simple redness 
without swelling, and usually is not followed by desquama- 
tion. This shows that it is due simply to a localized hyper- 
emia without inflammation. It is always of short duration. 
The redness disappears under pressure, but springs back 
again as soon as the pressure is removed. It occurs either in 
circumscribed patches of large or small size, or diffused over 
large areas. Subjective symptoms are often hardly notice- 
able. There may be some burning and tenderness, but there 
is never decided itching. The patient may rub his skin 
gently, but never scratches violently. There may be slight 
constitutional symptoms with fever of mild grade, or some 



222 DISEASES OF THE SKIN. 

« 

digestive disturbance, but these are not properly symptoms 
of the erythema, but rather of the underlying disease of which 
the eruption is but an accidental expression. For instance, 
two people may eat the same thing. In both there may be 
digestive disturbances. But one will have an erythema and 
the other will escape. 

This form of erythema may arise from either external or 
internal causes. Cases arising from external causes are 
localized, while those due to internal causes are general. 
Both are angioneuroses, and predisposed to by an inborn 
susceptibility — that is, idiosyncrasy, of the patient. 

In the first group we have Erythema simplex, under which 
are included E. Traumaticum and E. caloricum, due to the 
rubbing of the clothing, the effect of heat or cold, as of the 
sun or wind, and of various vegetable or chemical irritants. 
Many of these simple erythemas I have already described 
under the caption of Dermatitis, which see. They are usu- 
ally localized, and for treatment require only the removal of 
the irritating cause, and the application of a simple dusting- 
powder or ointment. The exciting cause continuing we have 
inflammation added, and a dermatitis produced. 

Erythema Pernio has been described under Dermatitis 
calorica, which see. 

Erythema Intertrigo, or simply Intertrigo, is an erythema 
occurring between two folds of skin. It is most commonly 
seen in fat infants in the folds of the skin of the neck and 
joints. It is also encountered in adults who are corpulent, 
and is often a very annoying trouble to women, where it 
frequently occurs underneath the hanging breasts. It also 
occurs in adults between the scrotum and inside of the thighs, 
under the prepuce, in the furrows alongside of the vulva, in 
the joints, and all other skin-creases. It is caused by the 
friction in walking and favored by heat and moisture. It 
is therefore more common in warm weather. If not at once 
and properly attended to, the decomposition of the sweat 
and sebaceous matters will aggravate it ; and the irritation 
being continued, an eczema will develop. It is, in infants, 
very common about the inside of the thighs, where the wet 



ERYTHEMA HYEERJEMICJJM. 223 

napkins cause and aggravate it. It is very often accom- 
panied by a disagreeable, cheesy odor, and, contrary to what 
obtains in other erythemas, there is exudation upon the skin 
in some cases. 

Diagnosis. The diagnosis from eczema is very often 
difficult. Indeed, they run into each other so imperceptibly 
at times that it is difficult to tell where erythema leaves off 
and eczema begins. But eczema itches more than erythema, 
it tends to spread further beyond the affected part, and its 
exudation is not only sticky, but also stains and stiffens 
linen. The location in the skin-folds should suggest an 
intertrigo. Happily, the differentiation is a matter of no 
great importance as the same treatment is applicable to 
both. 

In infantile syphilis we frequently have an eruption upon 
the buttocks and inside of the thighs that bears a decided 
resemblance to intertrigo. Here a correct diagnosis is of 
great importance. In syphilis the redness commonly ex- 
tends down the whole inside of the legs to the feet and 
soles, it is of a darker color, and there will be other symp- 
toms of the disease, such as snuffles, large or small papules 
to the outside of the red patch, mucous patches, and the 
like. In infants' asylums, where a great number of debili- 
tated as well as syphilitic children are received, opportuni- 
ties for the differentiation between syphilis and intertrigo 
frequently occur. 

Treatment. The treatment of intertrigo is simple. The 
opposing surfaces of skin must be separated by pieces of 
lint, the furrows must be kept perfectly clean, and dusting- 
powders of starch, talc, lycopodium, and the like must be 
freely used. To these powders oxide of zinc, boric acid, or 
other astringents may be added. Hardaway recommends : 

R. Thymol, gr. j. 

Pulv. zinci oleat., ^j. M. 

As a rule, powders answer better than ointments, though 
Lassar's paste, as given under Eczema, may be used. The 
treatment of intertrigo in infants is to be managed in the 
same way as eczema. (See under Eczema infantile.) 



224 DISEASES OF THE SKIN. 

Erythema Lceve is an obsolete term, which was employed 
to indicate the redness seen on oedematous limbs. Let it 

rest. 

Erythema Par atrimma belongs to the same category, only 
here it was the redness over bony prominences, as that pre- 
ceding a bedsore. 

We have now to consider the second group of erythema 
hyperaemicum, those which are due to internal causes. Here 
might be placed all the exanthematous fevers, as well as the 
drug-eruptions. But the first of these belong to the domain 
of general medicine, and the last will be found under Der- 
matitis medicamentosa. 

Erythema Fugax is, as its name indicates, a fugitive ery- 
thema — as it, were a prolonged blush. It is seen most often 
in children with some digestive disturbance, and its chosen 
location is the face. It lasts for a few moments or hours, 
and is seldom seen by the physician, although he will be 
told, not infrequently, by patients that they are annoyed 
by a flushing of the face after eating, exposure to cold, 
or mental emotion. It is to be managed like Urticaria, 
which see. 

Erythema Urticans is simply the first stage of urticaria. 
The term should be dropped. 

Erythema Eoseola, or simply roseola. While children 
are more subject to this form of erythema than adults are, 
it may occur in the latter. Most commonly it affects the 
whole body, but it may be localized. As it is due in most, 
if not all, cases to digestive disorders or other constitutional 
disturbance, it is usually ushered in with rise of tempera- 
ture, which may be pretty sharp, 103° or 104° F., furred 
tongue, restlessness, and the like. Soon the eruption ap- 
pears, which may be a blotchy redness, or in faintly marked 
papules, or in rings, or gyrate figures. The eruption lasts 
a few hours only, or, coming and going in different places, 
it may be prolonged for a few days. Besides digestive dis- 
orders, gout, changes of temperature, and the seasons of 
spring and autumn have been assigned as causes. 



ERY1HEMA HYPERJEMICUM. 225 

Diagnosis. In itself it is a matter of little moment, but 
as it resembles scarlet fever, rotheln, and measles, its diag- 
nosis is important. It differs from scarlatina in not having 
such severe constitutional symptoms ; in an absence of the 
strawberry tongue, swollen, reddened fauces, and enlarged 
glands ; in the rash coming out all over the body without 
following any regular course of development from the neck 
downward ; in the eruption being blotchy or papular, and 
not a diffused redness. After watching the case for a day 
the diagnosis will be evident by the clearing away of the 
disease wholly or partially. It differs from measles in an 
entire absence of catarrhal symptoms, and in its eruption 
not being crescentic, as well as in the irregularity of its 
course, the mildness of its symptoms, and the brightness of 
its color. It bears most resemblance to rotheln, and prob- 
ablv the two are often confounded. If there is a clear his- 
tory of contagion, or more than one member of the family 
affected at the same time, the diagnosis of rotheln is at once 
established. Rotheln is more pronounced on the extremi- 
ties, and the lesions are of a more stable character. In case 
of doubt as to diagnosis of roseola the patient should be 
regarded as having a contagious disease, isolated and care- 
fully watched. 

Treatment. Little need be done for the patient but to 
give a laxative, and to relieve symptoms. 

Erythema Neonatorum makes its appearance in the first 
few days of life, and is thought to be due to the influence 
of external and unusual irritants acting upon the tender 
skin of a newborn child. " The eruption consists of very 
minute red papules, seated upon a hypersemic base, which 
can be made to lose their color upon pressure. The lesions 
are most pronounced upon the back and breast, and fade 
away in a few days with slight desquamation of the most 
congested spots. The mucous membranes are unaffected, 
and there is no evidence of systemic reaction." (Hardaway.) 

Erythema Scarlatiniforme. A scarlatina-like erythema 
follows the ingestion of a number of drugs, and has been 
frequently mentioned in the section on Dermatitis medica- 
mentosa. The French authors describe a scarlatiniform 



226 DISEASES OF THE SKIN. 

erythema under the name of Erythemes scarlatiniformes 
recidivantes, which, according to Besnier, 1 who has pub- 
lished an excellent study of the affection, was first described 
by Fereol in 1876, at the Societe Medicale de Hopitaux de 
Paris. The disease is marked by redness, desquamation, 
and relapses. Its outbreak may or may not be preceded 
for one or two days by malaise and slight febrile movement. 
It begins on the trunk and invades the whole surface in a 
few hours or in two days. It is a diffused, uniform, in- 
tense, scarlatinal, or sombre-red eruption. There may be 
slight differences in the shade of color, or the redness may be 
punctate, or some pin-head vesicles may develop upon it. 
Sometimes the eruption is limited to a certain portion of the 
body ; sometimes the eruption is general, but not universal, 
normal islands of skin being found in the general redness. 
It comes out in patches that run together. There is gen- 
erally redness of the mucous membrane of the mouth and 
fauces. There is no thickening of the skin nor infiltration 
of mucous membranes. The skin burns, and there may be 
itching. Exfoliation of the skin begins almost as soon as 
the eruption is out, commencing at the point of invasion. 
The desquamation is general, and may be furfuraceous, or 
abundant and in large plaques. Upon the scalp it is fur- 
furaceous. The whole process may take but one or two 
days, or it may be prolonged for a month or six weeks. The 
hair and nails may be shed. The tongue is furred, and may 
desquamate, but never presents the papillae of scarlatina. 
After the beginning of the attack there is usually no fever, 
and the appetite is preserved. There may be albuminuria 
during the attack. The relapses, which are apt to occur 
after intervals of days, months, or years, are less pronounced 
and the patient's health is good in the interim. 

Etiology. The cause of the disease is very often ob- 
scure. The first attack has been observed to follow exposure 
to cold, the application of mercurial ointment, or the action 
of some other irritant. But it is difficult to explain why 
from such causes relapses should occur. Besnier thinks 

1 Annal de Derm, et de Sypli., 1890, i. 1. 



ERYTHEMA EXUDATIVUM. 227 

that in some cases the cause is a poison developed within the 
individual. In this way he would explain some of the 
erythemas developing during an acute urethritis, which some 
observers claim may arise independently of the taking of 
copaiba. Scarlatiniform erythemas occur occasionally in 
septicemic conditions, in typhus fever, in malaria of chil- 
dren, in sewer-gas-poisoning, and in various other conditions. 

Diagnosis. Brocq considers scarlatiniform erythema as 
one form of dermatitis exfoliativa, but it is distinguished 
from it by an absence of evening rise of temperature, by 
having no permanent effect upon the health, by running a 
shorter course, and by the skin not being dry, contracted, 
and shrivelled. It differs from scarlatina in the mildness 
of its constitutional symptoms ; by the course of the erup- 
tion ; by the absence of tumefaction of the fauces, and the 
strawberry tongue ; by the early desquamation ; by not be- 
ing contagious ; and by its tendency to relapse. If there is 
any doubt as to the diagnosis, the patient should be isolated. 
It differs from erythematous eczema in an entire absence 
both of thickening and moisture ; in being less itchy ; and 
in its rapid course. 

Treatment. The treatment is purely symptomatic. 

Erythema Exudativum. 

The second variety of erythema differs from erythema 
hypercemicum in the presence of an exudation into, not on, 
the skin, so that the patches are raised above the level of the 
skin, and in never involving the whole surface, but always 
occurring in circumscribed patches. The two varieties are 
alike in that the redness disappears under pressure to return 
at once when the pressure is removed. It is probable that 
erythema nodosum is really but a part of erythema multi- 
forme, as the two forms may be present at one time. But 
it is usually described apart, and although this may not be 
strictly accurate, it is convenient. 

Erythema {Exudativum) Multiforme, as its name indi- 
cates, is very multiform in its efflorescences. For a day or 
a few days before they appear there is some constitutional 



228 DISEASES OF THE SKIN. 

disturbance. This may be nothing more than slight malaise, 
the patient not feeling as well as usual. From these in- 
definite symptoms there are all grades up to fever of 104° 
F., headache, gastric disturbances, and severe muscular and 
articular pains like rheumatism. According to Besnier and 
Doyon, an erythema of the pharynx, or a pharyngitis, laryn- 
gitis, or bronchitis, often precedes or accompanies the outbreak 
of the eruption upon the skin. The eruption is most con- 
stantly seen upon the backs of the hands and feet, and here 
it commonly begins, though this is denied by Polotebnoff, to 
whom we are indebted for a most exhaustive and able study 
of erythema. 1 It also appears on the trunk and extremities 
more or less generally, coming out in crops, and preserving 
a rough symmetry. Sometimes it may remain confined to 
a single region, as the backs of the hands. Sometimes it 
occurs on the mucous membranes, as of the mouth and eyes. 
It is usually most marked and abundant about the joints 
should they have exhibited rheumatic pains. It is rare not 
to find lesions upon the backs of the hands. With the ap- 
pearance of the eruption there is a subsidence of the constitu- 
tional symptoms, though in many cases the patients are more 
or less definitely ill during the whole course of the disease. 
The eruption commences as a group of deep-red papules 
from pin-head to pea-size, conical or rounded, and this is 
called Erythema papulation. The eruption may continue 
as such ; or the papules may coalesce and form elevated 
patches, sharply marked against the sound skin ; or they 
may enlarge to the size of tubercles, thus forming erythema 
tuberculatum. If they still continue to enlarge, they be- 
come depressed in the centre and ring-shaped, the periphery 
being deep-red while the centre is purplish. This is called 
erythema circinatum or annulare. Sometimes it happens 
that the ring still enlarges by successive exudations, and 
then we will have ring within ring, the outer one pink, the 
next red, the next purplish, thus forming an iris-like play of 
colors that has been termed erythema iris. Two rings near 
each other and enlarging will after a time meet at the periph- 

1 Zur Lehre von den Erythemen. Hamburg, 1S87. 



ERYTHEMA EXUDATIVU3L 229 

eries, the points of contact will melt into each other and 
disappear, and then we shall have a large patch with a figure- 
of-eight or scalloped, raised border and a flattened centre. 
This is called erythema marginatum. It may travel over 
a large part of the trunk or the circumference of a limb, 
leaving a fawn-colored pigmentation, which soon fades. Or 
two rings meet, and each breaks, and only a gyrate line is 
formed, to which the name of erythema gyratum is applied. 
Sometimes, though rarely, the exudation is so abundant that 
the epidermis is raised in the form of vesicles or bullae. This 
is erythema vesiculosum, seu bullosum. Hemorrhage may 
take place into the bullae. 

It is uncommon to find all these forms present at the same 
time, nor must it be understood that one form necessarily 
evolves into the other. The evolution may stop at any 
stage ; most often at the papular stage. Nevertheless, more 
than one form is usually to be seen, so that the term multi- 
form is merited. Crocker says that in children multiformity 
is less the rule, the constitutional symptoms are more pro- 
nounced, and if vesiculation occur, the vesicles are more 
prone to become purulent and leave scars. 

The duration of the disease is from two to four weeks, but 
it may be extended by a succession of outbreaks for months 
or years. The eruption is attended by burning, rather than 
itching, and sometimes by a feeling of tension. Slight pig- 
mentation may be left, but it is transitory. Desquamation 
may follow the eruption, but is not common. In some 
patients there is a decided tendency to relapse at irregular 
intervals for years. In Prof. George Henry Fox's service 
at the Vanderbilt Clinic I have seen a boy with a relapsing 
bullous erythema of the face and ears that had appeared at 
intervals during ten years. The bullae were of large size, 
fully distended, and of irregular shape. They left depressed, 
pigmented cicatrices in some places. Similar cases have 
been reported by others, as, for instance, by Hardaway, who 
saw one case with relapses for four years ; and T. C. Fox, 
who saw two cases with a duration of sixteen years in each 
case. 

As complications of erythema multiforme, and especially 

11 



230 DISEASES OF THE SKIN. 

of erythema nodosum, have been reported endo- and peri- 
carditis, meningitis, pleurisy, pneumonia, and the like, but 
it is better to regard these diseases not as complicating the 
erythema, but as the primary diseases of which the erythema 
is a phenomenon. 

Erythema Iris. This very rare disease was formerly re- 
garded as a herpes, and is described in most text-books as 
herpes iris. Its other synonyms are hydroa, herpes circi- 
natus, and hydroa vesiculeux. It is only a form of erythema 
multiforme. It is seen sometimes along with other manifes- 
tations of erythema multiforme, or with herpes, though it 
usually occurs alone. It is located most often upon the 
backs of the hands and feet, and upon the arms and legs, 
but it may occur anywhere upon the skin as well as the 
mucous membranes. I have seen one case upon the buttocks 
as well as upon the elbows. According to Crocker, there 
are two varieties of the disease, one with a central vesicle or 
a purplish depression surrounded by one or more whitish 
rings slightly raised up by effused fluid ; the other with a 
central bulla with one or more rings of more or less dis- 
crete vesicles round it. Of these two the first is the most 
frequent. 

The first variety begins as a small erythematous papule 
upon which a pin-head-sized conical vesicle forms in about 
twelve hours. The vesicle grows larger and flattens, but 
preserves a red areola. When about a quarter of an inch in 
diameter the fluid is absorbed in the centre, leaving a pur- 
plish depression ; or only a ring of absorption occurs, so that 
there will remain a vesicle in the centre with a purplish zone 
about it, then a raised white ring, and around all a narrow, 
pink areola. This play of colors gives the name of iris. 
The patch may reach the diameter of half an inch, and then 
undergo involution ; or several patches may unite and form 
patches of one inch or more in diameter, and hemorrhage 
may take place into the bullae that may form. 

In the second variety, which is the hydroa vesiculeux 
of Bazin, round a central bulla a ring of split-pea-sized vesi- 
cles forms, the vesicles being either discrete or touching. A 
second or a third ring of vesicles may form outside of these, 



ERYTHEMA EXUDATIVUM. 231 

the skin between them being of a purplish tint. The bullae 
and vesicles may leave scars. Crusting also takes place 
from the breaking or drying of the vesicles. 

The lesions of both varieties are more or less symmet- 
rical, though a patch may develop on one side several days 
before the other. The duration is from three to four weeks 
or longer. Relapses are common. Burning is usually pro- 
nounced, and there may be some itching. From this de- 
scription it will be seen that the so-called herpes iris is 
really an erythema. 

Erythema Nodosum, also called dermatitis contusiforme, 
and erytheme noueux (Fr.), is more common than erythema 
iris, but not nearly so common as erythema multiforme. It 
is only a variety of erythema multiforme, as it may occur as 
a part of that disorder. In the vast majority of cases it 
occurs alone. Its prodromal symptoms are substantially 
the same as those of erythema multiforme, but its rheumatic 
pains are more pronounced and always present. There are 
also tenderness and pain over the tibiae. After a few days 
of prodromata, round or, more often, oval, bright or rosy 
red swellings appear over the tibiae, with their long axis 
vertical. These are -from nut to egg-size ; raised ; their 
borders merge gradually into the surrounding skin ; they are 
painful and often exquisitely tender ; firm at first, but may 
be semi-fluctuating afterward ; and their color darkens to a 
dark red, then purple, and in undergoing absorption they 
present the appearance of a black-and-blue spot from a 
bruise. The color at first disappears under pressure, to 
spring back when the pressure is removed. The changes of 
color subsequently seen are due. to the gradual absorption of 
the coloring-matters of the blood deposited in the tissues. 
There are usually not more than a dozen lesions, generally 
less. They are most frequently located over the tibiae, but 
may occur as well upon the arms, scapulae, thighs, and 
mucous membranes. They are roughly symmetrical. The 
duration of the disease is, like that of other erythemas, two 
to four weeks. 

Etiology. The causes of erythema exudativum are not 
fully determined. It is probably due to some toxic condi- 



232 DISEASES OF THE SKIN. 

tion of the blood, which may develop in the individual or be 
derived from without. It occurs more commonly in women 
than in men, and in young adults rather than in old people. 
Erythema nodosum is said to be most frequent in children. 
It is most frequent in the spring and autumn seasons, in 
which dampness and cold winds prevail, and sudden changes 
of temperature are common. The papular erythema is very 
often seen in recently arrived immigrants. Rheumatism 
has a well-marked causal relation to erythema nodosum, 
and, it may be, to the other forms. Syphilis seems to be 
an etiological factor of some weight in the production of 
erythema nodosum. Some years ago I saw in the service 
of Professor E. B. Bronson, in the New York Polyclinic, a 
well-marked instance of this in the course of recent syphilis 
in a woman. Many cases seem to be due to systemic poison- 
ing either by some infectious disease or by auto-infection. 
It is seen with cholera, influenza, and the exanthemata ; 
with indigestion, pregnancy, parturition, menstrual disturb- 
ances, kidney diseases, and various other internal or sys- 
temic disorders. Sometimes the disease seems to be a pure 
angioneurosis. Cases of erythema multiforme recurring 
with recurring attacks of gonorrhoea have been reported. 
These appear as reflex angioneuroses without the ingestion 
of balsamics in the treatment of the urethritis. Cases of 
erythema multiforme not infrequently follow the ingestion 
of drugs ; at least they are almost identical with it in ap- 
pearance. Sometimes, according to Polotebnoff, it seems to 
be an abortive form of prevailing epidemics. Cases cer- 
tainly should be watched carefully in connection with other 
symptoms, as they may be but part of the prodromata of 
some grave disorder. I have seen two cases in which a well- 
marked erythema multiforme preceded for about ten days the 
outbreak of typhoid fever ; the erythema then disappearing 
and the characteristic typhoid eruption coming in due course. 
Many of the subjects of erythema are debilitated. Indi- 
vidual predisposition probably plays an important role in the 
etiology of some cases, especially in the relapsing ones. 

Pathology. All forms of the disease show not only 
hyperemia, but also inflammatory effusion both of fluid and 



ERYTHEMA EXUDATIVUM. 233 

leucocytes. Upon the amount of this fluid depends the char- 
acter of the lesion. If small in amount, it will simply push 
up the epidermis into a papule or tubercle ; if of larger 
amount, we shall have vesicles and bullae. There is also an 
escape of the coloring-matter of the blood into the tissues. 
(Crocker.) 

Diagnosis. If the characteristics of erythema multi- 
forme are borne in mind, little difficulty in diagnosis will 
arise. These are the sudden occurrence of raised, bright, or 
rosy-red lesions, located by preference upon the backs of the 
hands and feet ; and the color that fades away entirely under 
pressure, to return again when pressure is removed, and in 
disappearing leaves stains. It most resembles urticaria, but 
differs from it in having more stable lesions of more varied 
shape ; in absence of wheals ; in occurring particularly on 
the backs of the hands and feet ; and in burning rather than 
itching. The papular form differs from papular eczema in 
its chosen locations ; in its burning rather than itching ; in 
its papules being larger and never developing vesicles nor 
forming patches ; in an absence of thickening of the skin ; 
in disappearing completely under pressure ; in tending to 
get well without treatment; and in leaving stains. The 
nodes of erythema nodosum differ from syphilitic gummata 
in occurring suddenly and not gradually. In syphilis the 
redness does not occur until after the node has existed for 
some time, and the nodes are not tender nor developed 
symmetrically. Moreover there would be other evidences 
of syphilis. 

Treatment. Villemin 1 maintains that iodide of potas- 
sium, in doses of at least thirty grains a day, is almost a 
specific, and will abort relapses. The experience of Bes- 
nier and others has not been in accord with that of Ville- 
min. Quinine, twenty to thirty grains a day, and salicy- 
late of soda in fifteen-grain doses three or four times a day 
sometimes abort or check the disease. Arsenic may be tried 
in chronic cases. The treatment is mainly symptomatic, 
and directed to relieving the constipation, regulating the 

] Gaz. hebdom., May 24, 1886. 



234 DISEASES OF THE SKIN. 

diet, aiding digestion, ameliorating rheumatism, or toning 
up the system. In obstinate cases the patient had best be 
kept in bed. Locally any alkaline lotion will afford re- 



lief, such as 






B . Pulv. calamin. prep , 
Zinci oxid., 


By; 


4 
3 


Liq. calcis, 
Or, 


lij; 


100 


R. Liquor plnmbi subacetatis, 
Aquse, 




3 

100 



M. 

M. 

Or, lead and opium wash. 

Sometimes a simple dusting-powder will do as well. In 
erythema nodosum the patient should be kept in bed, and 
often the lotion is more agreeable to the patient when used 
warm. Salicylic acid or salicylate of soda internally may 
afford relief to the sometimes intense pains. Regulation 
and simplification of the diet, and the administration of 
diuretics or tonics, according to the nature of the case, will 
do good in the disease as seen in immigrants. 

Erythema Centrifuge. See Lupus erythematosus. 

Erythema Elevatum Diutinum. Under this caption 
Crocker 1 and others describe a form of erythema that is said 
to occur in girls with a rheumatic history. It develops over 
the articular prominences of the fingers, elbows, and knees, 
and also on the palms, toes, and buttocks. Its lesions are 
nodular with a tendency to coalesce into elevated infiltrations 
that are most marked on the palms. They tend to persist, 
but may undergo involution. Their color is at first pink, 
but soon becomes purple. The older lesions become firm 
and almost cartilaginous, and are always incompressible. 
The lesions are always sharply defined against the skin. 
Microscopically they are an inflammatory process accom- 
panied by the production of fibrous tissue. 

Erythema Gangrenosum, though described as a disease, 
is probably always a feigned eruption, and needs no descrip- 
tion here. 

1 Brit. Journ. Dermat, 1894, vi. 1. 



ERYTHBASMA. 235 

Erythema Induratum is a disease first described by 
Bazin as erytheme indure des scrofuleux. It consists in an 
eruption of nodular lesions that may remain deep-seated for a 
considerable time, so that they can be made out only by pal- 
pation. After a while the overlying skin becomes red, and 
later violaceous, and they resemble erythema nodosum. In 
size they vary from that of a hazelnut or larger on the 
legs, to smaller on the fingers. They are round or ovoid 
in shape. They are usually few in number and discrete, 
but may be numerous and confluent. They are indolent in 
their course, and may undergo involution, or suppurate, or 
necrose en masse. Poly cyclic ulcers may form. There may 
or may not be pain or tenderness. They are located most 
often on the legs in young people, especially in girls of poor 
general health and circulation, and who suffer from chil- 
blains in winter. 

They differ from erythema nodosum in their more cir- 
cumscribed form, firmer consistence, darker color, deeper 
seat, absence of tenderness, tendency to ulcerate, and more 
protracted course. Syphilitic gummata are not bilateral, 
and usually other symptoms of syphilis can be found. 

The treatment consists in rest in bed, elevation and com- 
pression of the legs, and general tonics. 

Erythema Mamelonne. See Erythema roseola. 

Erythema Migrans. See Erysipeloid. 

Erytheme Noueux. See Erythema nodosum. 

Erythema Papuleux Desquamatif (Vidal). See Pity- 
riasis maculata et circinata. 

Erythrasma (E 2 r-i 2 -thra 2 z-ma 3 ). A contagious parasitic 
disease of the skin, occurring especially in the groins and 
axillae in the form of sharply defined, brownish- red, desqua- 
mating patches, bordered by a fringe of broken and partly 
detached epidermis. (Foster.) 

This affection of the skin is very rarely seen in this coun- 
try. This may be because it gives no trouble to the patient, 
and therefore he does not apply to the physician. It begins 
as a little yellowish point that soon becomes a lentil-sized 



236 DISEASES OF THE SKIN. 

macule, and grows into a patch the size of a silver dollar or 
the hand. Several patches join together so that large sur- 
faces may be involved. The patches are oval or disk-shaped. 
They are located in the situations where intertrigo is liable 
to occur, such as the axillse, groins, and where the scrotum 
comes in contact with the thighs. The latter situation is 
declared by Besnier to be nearly always the original site of 
the disease. From these favorite locations the disease may 
spread to the chest, abdomen, or thighs. Besnier 2 met with 
a case involving the thigh down to the knee. The color of 
the patches is orange, red, yellowish, or brownish, or, in 
the folds of the skin, pale red. Their outline is sometimes 
marked by a raising of the epidermis. Their surface is 
dull-looking, and feels less smooth than normal. They are 
quite tenacious, cannot be readily rubbed off, and show little 
tendency to spontaneous recovery. There may be slight 
itching, and a very little delicate scaling. 

Etiology. The disease occurs most often in men, and 
never in children. It is due to a parasite called the micro- 
sporon minutissimum which is described by Balzer 2 as con- 
sisting of long, wavy mycelia, that are rarely branched ; and 
of very fine spores. High powers of the microscope are 
necessary to see them. They are located exclusively in the 
corneous layer of the skin. He regards them as a common 
form of parasite that produces the disease in some people 
only on account of the peculiar fermentation of their skin 
secretions. 

Diagnosis. The disease resembles both chromophytosis, 
eczema marginatum, and chloasma. It differs from chromo- 
phytosis by the darkness of its color ; by the absence of dis- 
tinct rather large scales that can be lifted by the nail ; by 
its location, sparing the trunk, except by extension ; and 
by the character of the microscopical appearances. From 
eczema marginatum it is distinguished by an absence of all 
inflammatory symptoms, by not being more pronounced at 
the periphery than at the centre, and by the microscopical 

1 Journ. de Med. et de Chirurg. prat., 1883, liv. 351. 

2 Annal. Derm, et Syph., 1884, v. 597. 



EXANTHEMATOUS FEVERS. 237 

appearances. From chloasma it differs by being a para- 
sitic and not a pigmentary disease, and by the change it 
causes in the feel and texture of the skin, and by the effect 
of treatment. 

Treatment. It is curable by the same means as is 
chromophytosis, namely, by the tincture of iodine ; pyro- 
gallol ; chrysarobin ; bichloride of mercury ; or sulphur. 
It is more obstinate than is chromophytosis, and quite as 
prone to relapse unless thoroughly eradicated. 

Erythromelalgia (EVP-thro-me^-a^'gP-a 3 ) is a nervous 
disease characterized by the appearance of a persistent patch 
of congestion, often on the sole of the foot, attended with 
swelling and pain. (Foster.) 

Esthiomene (E 2 s-te-o-me 2 n). This is a disease of the ano- 
vulvar region that was described by Huguier, 1 and about 
which there is a good deal of uncertainty. It has been vari- 
ously considered as a form of lupus, syphilis, elephantiasis, 
and epithelioma. " It is characterized by a leaden or vio- 
laceous hue of the parts, and their simultaneous alteration 
of shape, induration, thickening, ulceration, destruction, 
hypertrophy, and infiltration, so that the orifices and canals 
of the vulvo-anal region may be at the same time ulcerated, 
enlarged, and constricted, and its grooves and cutaneous 
and mucous folds exaggerated, thickened, and the seat of 
more or less extensive and deep ulcerations and cicatrices ; 
without pain, without directly threatening life, and for a 
long time without affecting the constitution/' (Foster.) 

Exanthematous Fevers. These concern us as dermatolo- 
gists only in the matter of diagnosis. They are chiefly lia- 
ble to be mistaken for different forms of erythema hyper- 
semicum,and their differentiation from these has been already 
considered. (See Erythema.) Besides this, measles must 
be differentiated from the erythematous syphilide ; variola 
from a papulo-pustular syphilide and acne ; scarlatina from 
erythematous eczema, and varicella from vesicular eczema 
and impetigo contagiosa. Consideration of the constitu- 

1 Mem. de l'Acad. de Med., 1869, p. 507. 
11* 



238 DISEASES OF THE SKIN. 

tional symptoms, the distribution of the eruption, and the 
course of the disease in question should leave little doubt as 
to diagnosis, and in any event watching the case for a day 
or so will decide it positively. See also Morbilli, Scarlatina, 
Rotheln, etc. 

Farcy. See Equinia. 

Favus (Fa 3/ vu 3 s). Synonyms : Porrigo lupinosa, seu 
favosa, seu lavalis, seu scutulata ; Porrigophyta ; Tinea 
favosa, seu vera, seu ficosa, seu lupinosa, seu maligna ; 
Trichomykosis or Dermatomycosis favosa ; (Fr.) Teigne 
faveuse, teigne du pauvre ; (Ger.) Erbgrind ; Crusted or 
honeycomb ringworm, Scall head, True porrigo. 

A contagious vegetable parasitic disease due to the Acho- 
rion Schoenleinii, and characterized by the presence of dis- 
crete or confluent, circular, pale sulphur-yellow cupped crusts, 
or by asbestos-like masses of grayish friable crusts ; by loss 
of hair producing irregularly shaped, disseminated, red, 
bald patches ; by permanent atrophy of the scalp ; and by 
running a chronic course. 

Symptoms. Favus affects both the scalp and the non- 
hairy skin as well as the nails and mucous membrane. We 
shall first describe it as it affects the scalp. It begins either 
as one or more scaly erythematous spots ; or as minute yel- 
lowish puncta ; or as a group of vesicles smaller than those 
met with in ringworm. These develop into small sulphur- 
yellow cupped crusts about the hairs. When the case is 
seen by the physician the early stage is usually passed, and 
he will find that the hair is dry and lustreless, and has fallen 
out in places, leaving irregularly shaped bald patches, of all 
sizes, and of pronounced red color. Upon both the bald 
patches and the parts still covered with hair the sulphur- 
yellow cup or saucer-shaped crusts will be found, with raised 
or rounded edges, and with one or several hairs growing out 
of the middle of them. There will be more or less scaling, 
and, if the disease be of some age, thick mortar-like crusts 
of grayish color. In some cases when first seen it may be 
impossible to find the characteristic crusts, scutula as they 
are called, they being obscured by the mortar-like masses. 



FAVUS. 



239 



Fig. 24. 




Case of favus of hand showing scutnla. Side view. 



Fig. 25. 






Favus ol hand, front view. 



240 



DISEASES OF THE SKIN. 



In some cases the scutula are wanting. If we approach 
near enough to the patient, we will appreciate a peculiar 
odor variously described as that of mice, straw, or of a 
menagerie. 

The crusts, scutula, or favi are situated about the hair 
follicles. They are from pin-head to split-pea size, accord- 
ing to age. At first they are covered with a thin layer of 
epidermis, but later the edges are free. When they are 
picked off they leave a moist depression which soon fills up, 
or a pustule, or an atrophied spot. The. color is pale or 

Fig. 26. 




Favus of knee. 

sulphur-yellow, or, if of long standing, it may be a dirty or 
greenish-yellow. The crusts are discrete and disseminated 
or grouped ; sometimes they coalesce ; they are firm to the 
touch, and when crushed between the fingers impart a feel- 
ing of crumbling like mortar. There is a slight zone of 
redness about them. Though they may not be seen at the 
first examination, if the scalp is cleaned off and left to itself 
they will form in the course of two or three weeks. The 
baldness is rarely in well-defined patches. The patches may 



FAVUS. 241 

be few iii number, or so numerous that the hair occurs only 
in islands. At first their color is inflammatory red ; later 
they become white and atrophic in appearance. The bald- 
ness is permanent. The hair is dry from the first ; later it 
becomes brittle and split longitudinally ; but it is never so 
easily broken as in ringworm, and can easily be pulled out 
with its roots. There is itching of the scalp. That is the 
only subjective symptom. Pustulation does not belong to 
the disease, but may be an accidental complication. Other 
complications that may arise are pediculosis, eczema, and 
enlargement of the cervical glands. 

Occurring upon non-hairy parts it undergoes materially 
the same development and forms the characteristic cups. 
Sometimes it will take the circular form of a ringworm with 
the development of vesicles, and resemble it very closely, 
only that the cups will be sure to develop somewhere. (Figs. 
24, 25, and 26.) The scutula develop around the lanugo 
hairs. There may be only one patch of favus or a large part 
of the body will be covered by the fungous growth in the form 
of sulphur- yellow cupped crusts and asbestos-like masses. 
On the non-hairy parts the disease is easier of cure than on 
the scalp, and is not so apt to leave scars. In a single case, 
that of Kaposi, the favic fungus was found implanted upon 
the mucous membrane of the stomach. The nails may be 
affected, either in the form of onychitis beginning at the 
side of the nail, hardly distinguishable from the same dis- 
ease developed from common causes ; or in having a scutu- 
lum develop in the nail-bed and showing through the nail. 
This is rare. The occurrence of favus upon the head will 
give a clue to the origin of the onychitis. 

Etiology. The disease is due to the implantation and 
growth of the Achorion Schoenleinii primarily in the scalp 
and secondarily in the hair. It is contagious, but not so 
much so as is ringworm. It used to berare in this city, but 
on account of its being constantly imported from Europe 
the disease is on the increase, and cases are beginning to 
occur in native Americans. Its course is very chronic, and 
it shows less tendency than ringworm does to spontaneous 
recovery about the time of puberty. Though children are 



242 



DISEASES OF THE SKIN. 



more commonly affected than are adults, it is by no means 
uncommon to see it in full activity in people well advanced 
in life. It has been asserted that the strumous diathesis 
predisposes to favus, but this is doubtful. Like all other 
parasites it requires a certain soil upon which to grow, and 
does not affect all skins. It is a disease common in mice, 
and may occur in rabbits, dogs, cats, and fowls, and be a 
source of contagion for the human race. 

Pathology. The cups are composed almost wholly of 
the fungus, which consists of flat, narrow, branching, and 
inosculating mycelial threads -g-^Q-th of an inch in diameter, 
and of pale gray color ; and of small spores of round, oval, 
flask, or dumb-bell shape, and of a pale greenish color. 
(Figs. 27, 28 ) The spores gain access to the skin by the 



Fig. 27. 




% 
Achorlon Schoenleinii. (After Kaposi.) 



^ 



orifices of the hair follicles, and, after remaining there un- 
disturbed, began to grow in the upper part of the hair sac, 
and between the superficial layers of the epidermis, and 
subsequently invade the hair, growing in its cortical sub- 
stance. The cup may be formed either by the sinking in of 
the more central portion of the mass, or on account of the 
central portion being attached to the hair so firmly that it 
cannot so readily give way and bow out under the pressure 
of the growing fungus as do the parts further away from 
the hair. The atrophy of the skin is largely due to the 



FA VUS. 



243 



pressure of the growing fungus, which is powerful enough 
to destroy the cranial bones of mice ; and in part to the 
inflammation of the skin produced by the presence of the 
fungus. 

Fig. 28. 




A chorion Schoenleinii in hair shaft and follicle. (After Kaposi.) 



The question of the unity or non-unity of the fungus of 
favus is still unsettled. Several fungi, Quincke says three, 
and Unna asserts that there are nine, seem capable of pro- 
ducing the clinical picture of the disease. Other competent 
bacteriologists hold that the apparently diverse fungi are 
either different stages of development of the same fungus or 



244 DISEASES OF THE SKIN. 

due to different culture-media. It is distinct from the tri- 
chophyton fungus. 

Diagnosis. Most cases of favus are easy of diagnosis : 
the sulphur-yellow cupped crusts ; the asbestos-like grayish 
masses ; the red, atrophic bald spots, with tufts of dry and 
more or less kinky hair in them ; and the peculiar odor 
being so well marked. Ringworm has none of these features. 
Moreover, it occurs in the form of circular, circumscribed, 
only partially bald patches covered with grayish scales in 
moderate amount; has characteristic nibbled-off " stumps " 
of hair ; and under the microscope we find the spores less 
abundant, smaller, and more uniformly round than in favus. 
It must be confessed, however, that without the clinical fea- 
tures of one or the other disease, none but a most expert 
microscopist could make the diagnosis in a doubtful case 
by the microscope alone. In eczema baldness is very rare, 
and we will usually find a characteristic patch of the disease 
behind the ear ; its crusts are greenish and tenacious, not 
gray and friable ; the hair is matted by the sticky exuda- 
tion ; and if discrete impetigo lesions are present, they will 
contain pus, and not be solid like the favus crust. Leaving 
the scalp alone for a time will decide the matter, as scutula 
will be sure to form if the disease is favus. Sehorrhoea causes 
a general thinning of the hair, the scalp is not atrophic, 
there are no scutula, and no achorion in the hair and scalp. 
Lupus erythematosus resembles favus only in producing 
atrophic red spots. There will usually be patches of the 
disease elsewhere, and its whole course is different. Psoriasis 
does not cause atrophic bald spots, and rarely occurs on the 
scalp alone. Alopecia areata presents more or less circular 
bald areas, but these are white, smooth, and of normal tex- 
ture, and there is no fungous growth in the hair. Alopecia 
from syphilis in its early stage resembles favus more closely 
than any other disease of the scalp; but it occurs primarily 
at a later age than does favus, it comes on more suddenly, 
there is no history of crusts, and there will be other evi- 
dences of syphilis on the body, and (especially in women) 
the broken arch of the eyebrows. 

Treatment. In the treatment of the disease we need 



FAVUS. 



245 



three weapons — patience, perseverance, and parasiticides. 
Before using the last we should always epilate, pulling the 
hair out systematically from day to day so that eventually 
all the hair of the scalp is plucked. To do this we may use 



Fig. 29. 




Piffard's epilating forceps. 



the epilating forceps (Fig. 29) ; or Kaposi's method of 
grasping the hair between the thumb and a spatula or piece 
of stiff cardboard held firmly in the hand ; or, in dispensary 
practice, we may employ epilating sticks, made, according 
to Bulkley, of — 



&. Cerse flavse, 


3ij- 


Laccse in tabulis, 


3 IV. 


Picis burgundicae, 


gx. 


Gummi damar. , 


3J SS 



M. 

These ingredients are to be melted together, and then 
moulded into sticks of a half-inch or more in diameter. 
They are to be used by melting the end, and when warm 
applying it to the hair with a sort of boring motion. When 
cold they are to be suddenly twisted off, when, of course, 
they will bring many hairs with them. The u calotte," or 
pitch-cap, used to be used for this purpose, but was given 
up because it caused the death of several patients. Kaposi's 
method is the best of all. If the head is greatly crusted, 
the crusts should be cleaned off by means of soaking the 
scalp with oil for a day or two, and then washing with soap 
and water. For an oil we can use sweet oil, sweet almond 
oil, or cotton-seed oil, with three per cent, of carbolic or 
salicylic acid. The use of these oils should be continued 
throughout the whole course of the disease to prevent the 
spread of the fungus upon the scalp of the patient and to 
other people's scalps. After the first washing we should 
allow the scalp to go unwashed for several days at a time, so 
as to permit the full action of the parasiticide. 



246 DISEASES OF THE SKIN. 

After the cleansing and the epilation, the parasiticide 
must be rubbed and worked into the scalp. Of these there 
are many from which to choose. Sulphur ointment is one 
of the best, if properly and persistently used. Other oint- 
ments are thymol, naphthol, resorcin, and pyrogallol in 5 to 
10 per cent, strengths, and those of the ammoniate or yel- 
low sulphate of mercury. Or solutions may be employed, 
as bichloride of mercury, two grains to the ounce of ether 
or alcohol ; the oleate of mercury or copper, 10 to 20 per 
cent. ; tar ; oil of cade ; creosote in ether or alcohol ; sul- 
phurous acid in full strength ; or salicylic acid, five per 
cent, in oil. Hydronaphthol plaster does good service in 
favus, used according to the method described under Tricho- 
phytosis, which see. Peroni 1 recommends spraying the head 
with acetic acid used in an atomizer, after covering any ex- 
coriated points with diachylon ointment on a piece of cloth. 
At first the scalp feels cold. Hypersemia follows, which 
last about forty-eight hours and disappears leaving slight 
desquamation. When the hyperaemia lessens, the acid is to 
be again used. When there are no excoriations the head is 
to be washed every morning and evening with water and 
corrosive sublimate soap. Busquet 2 recommends sopping 
on daily a solution of 



R . Essence of cinnamon, 10 

Spts. aether, sulph , 30 



M. 



Besnier and Doyon 3 recommend as a preparatory treat- 
ment for favus that the hair be cut from off and around all 
the patches, and the whole head then covered for two or 
three hours with equals parts of soft-soap and lard. This 
is to be washed off with warm water, and the head is to be 
kept covered during the night with a cap of rubber or other 
impermeable cloth. The next morning the head is to be 
washed perfectly clean, bathed with a solution of boric acid 
(25 to 1000), and covered with borated lint soaked in the 
following solution : 

1 Annal. Derm. et. Syph., 1891, ii. 797. 

2 Ibid., 1892., ii. 269. 

3 Kaposi's Mai. de la Peau. French ed. Paris, 1891. 



FAVUS. 247 



R . Sodii salicylati, 25 

Sodii bicarbonati, 10 

Aquse, 1000 



M. 



Over all comes the impermeable cap. After a few days 
the dermatitis will disappear and the scalp will be clean, and 
then epilation must be practised, the hairs being pulled not 
only from the patches, but for about a half-inch about them. 
Epilation is to be repeated every week until no longer any 
trace of redness about the hairs exists, and the head is to be 
kept covered with the impermeable cap. Every evening 
the whole head is to be rubbed with an antiparasitic oint- 
ment such as : 

R. Bals. Peruv. vel 

01. cadini, 2 to 5 parts. 

Ac. salicyl.,j -- x g „ 

Kesorcin, j 

Sulph. precip., 5 to 15 " 

Lanolini, ~\ 

Vaselini, ' aa p. se. ad 100 parts. 

Adepis, J M. 

Every morning the whole scalp is washed with tar soap, 
and each favic patch is soaked with the following : 

R. Alcoholis (90 per cent.), 100 parts. 

Ac. acetic, (crystals \ \ to 1 part. 
Ac. boric, 2 parts. 

Chloroformi, 5 " M. 

Then each patch is to be accurately covered with mercu- 
rial plaster. 

Favus of the non-hairy parts of the body usually yields 
readily to the removal of the crust and the use of a parasiti- 
cide. 

Favus of the nail may be treated by the constant applica- 
tion of a mercurial, resorcin, or hydronaphthol plaster. If 
the disease is limited to one or two points, they may be cut 
down upon and the remedy applied directly. Sometimes it 
may be necessary to remove the whole nail. 

After a case of favus has been faithfully treated for a num- 
ber of weeks and looks as if it were well, it should be let 



248 DISEASES OF THE SKIU. 

alone and watched carefully for a long time. Any red 
point that appears is evidence that the disease is cropping 
up again, and should be immediately attacked. 

Pkognosis. The prognosis is good, provided the case is 
faithfully and energetically treated. Relapses will surely 
occur if any of the fungus remains in the scalp. A cure 
takes months or years to effect. Favus of the nail is spe- 
cially rebellious to treatment, and may cause permanent de- 
struction to the nail. 

Feigned Eruptions. It is a good rule to consider the 
possibility of malingering whenever we meet with an erup- 
tion that does not correspond to any type eruption, and at 
the same time is not due to the action of drugs ingested or 
locally applied, nor to irritants that have come accidentally 
in contact with the skin. Eruptions are feigned mainly by 
three classes of individuals, namely : Soldiers, sailors, or con- 
victs for the purpose of shirking work ; paupers for the pur- 
pose of gaining admission to hospitals ; and hysterical young 
women for the purpose of exciting sympathy. Not only are 
feigned eruptions peculiar in appearance, but also it will be 
observed that they are usually on the left side of the body, 
as they are commonly due to acids applied by the right 
hand ; or on the legs. The back is seldom the seat of these 
lesions. Most commonly they are irritative lesions, such as 
would be due to tartar emetic ointment, croton oil, nitric 
acid, carbolic acid, mustard, and the like. If made by acids, 
the lesions will often show lines radiating from the main 
mass showing where the acid has run further than intended. 
Some of the lesions imitate genuine disease with amazing 
cleverness. 

It is impossible here to give a full account of the feigned 
eruptions. A good list is given by Van Harlingen, 1 and to 
this I would refer the reader. Sycosis by tartar emetic 
ointment and tar ; favus by means of acids ; alopecia areata 
by means of plucking the hair ; ringworm by means of de- 
pilatories; scabies by means of excoriating with a fine 

1 Morrow's System of Gen.-urin. Dis., Syph. and Dermat. , vol. iii., 
N. Y., 1894. 



FIBROMA. 249 

needle ; various forms of ulcer and pustular eruptions by 
means of acids and caustics ; gangrene in the same way, all 
these and others have been simulated. 

Feuergiirtel. See Zoster. 

Feuermal. See Nsevus. 

Fever Sore. See Herpes facialis. 

Fibroma (Fi-bro'ma 3 ). Synonyms : Fibroma molluscum ; 
Molluscum fibrosum ; Molluscum simplex ; Molluscum 
pendulum. 

Fibromata are soft tumors of the skin that are composed 
of a hyperplasia of the connective tissue as well as the 
subcutaneous tissue, and occur in various shapes, colors, 
and sizes. The most commonly encountered form of 
fibroma is 

Molluscum fibrosum. These may be of the color of the 
skin, or pinkish, or even brownish or brownish-red ; most 
commonly they are of normal color. They may be rounded, 
flattened, sessile, or pedunculated, but always raised above 
the level of the skin. They may hang down like polypi. 
The skin over them feels soft and of normal texture, or it 
may be thickened or atrophied. A hair sometimes grows 
from them. There may be but one or two present, or there 
may be hundreds of them so that the body is strewn over from 
head to foot with the variously shaped tumors. The trunk is 
the most common location for fibromata, but they may occur 
on all parts and involve even the mucous membranes. (Fig. 
30.) They give rise to no inconvenience except on account 
of their size, which sometimes may be that of a child's head 
or larger. Their usual size is from that of a cherry to that 
of a walnut. Many of them show a slow growth, while 
many are stationary, and some may involute. Comedones 
of large size may accidentally form in some fibromata. The 
larger ones may ulcerate. All of them feel soft, while the 
larger ones may be elastic to the touch. When they hang 
down in the form of large skin-folds which have undergone 
hypertrophy, the term fibroma pendulum is applied to them. 
Dermatolysis (which see) has been considered as a form of 



250 



DISEASES OF THE SKfN. 



fibroma. According to some authorities, fibrous moles and 
soft warts are but forms of fibroma. 



Fig. 30. 




Multiple fibromata. 



Etiology. Fibromata usually appear in childhood, 
though they may not do so until later in life. They are 
sometimes hereditary. They tend to increase with advanc- 
ing age — that is, they are not so large or numerous in 
children as in adults. Hebra taught that children with 
fibromata were stunted both physically and mentally, but 

1 From a photograph of a case of Dr. E. T. Tappey, of Detroit. 



FLACHENKREBS. 251 

this is not always true. By some authorities they are 
regarded as related to neuro-fibromata. 

Diagnosis. Molluscum fibroma differs from molluscum 
contagiosum by not having a central depression, and by 
being of the normal color of the skin. They are also usually 
far more numerous. From fatty tumors they differ in not 
being lobulated, and in being pedunculated, and less flat. 
Sebaceous cysts are not so numerous, and their contents 
can be squeezed out to large extent, while fibromata are 
solid. 

There is another form of fibroma to which the name 
Acrochordon is applied. They occur as small soft, pedun- 
culated, vascular, and mole-like lesions upon the face, 
shoulders, and elsewhere in elderly people whose skin is 
degenerated. They often take the form of little hernia-like 
sacs of skin when their contents have been absorbed. 

There is also a hard variety of fibromata called desmoids. 
These occur as round or oval compact smooth nodules, from 
hemp-seed to pea-size. 

Treatment. They may be snipped off with scissors or 
tied off with ligature if pedunculated. If non-pedunculated, 
they may be destroyed by electrolysis, or excised. If of 
large size, they must be excised. The galvano-cautery may 
be used to destroy any form. 

Fibroma Fungoides. See Mycosis fungoide. 
Fibroma Lipomatodes. See Xanthoma. 
Fibroma Molluscum. See Fibroma. 
Fibromyoma. See Myoma. 
Figwart. See Verruca. 

Filaria Sanguinis Hominis. See Elephantiasis. 
Filaria Medinensis. See Guinea-worm disease. 
Finnen. See Acne. 

Fischschuppenausschlag. See Ichthyosis. 
Fish-skin Disease. See Ichthyosis. 
Flachenkatarrh der Haut. See Eczema, 
Flachenkrebs. See Epithelioma. 



252 DISEASES OF THE SKIN. 

Fleckenmal. See Nsevus pigmentosus. 

Flechten. May mean Herpes, or (nassende) Eczema, or 
(fressende) Lupus. 

Flea-bites occur in the form of small red puncta which 
may or may not be in the centre of wheals. They some- 
times bear a close resemblance to urticaria that has been 
scratched. The grouped arrangement of the lesions and 
the limited areas upon which they occur suggest their origin. 

Flesh Worms. See Comedo. 

Fluxus Sebaceus. See Seborrhoea. 

Folliculitis means an inflammation of the hair follicles. 
When the hairs involved are those of the beard we have 
F. barbce, or sycosis, which see. The hair follicles on the 
extremities, especially of the legs, may become inflamed on 
account of some irritant applied to the skin. One form of 
this is tar acne. In workers in oil or paraffine it is no un- 
common thing to see each hair on the legs, especially the 
thighs, standing in the center of a red papule or pustule. 
The cure consists in removing the cause, in cleansing the 
parts, and the application of an alkaline soothing-lotion. 

Folliculitis Decalvans. Under the name of folliculites et 
perifolliculites decalvantes agminees Brocq has described 
a form of inflammation of the hair follicle closely allied to 
sycosis. Besnier has given the same disease the name of 
alopecies cicatricielles innominees. It is characterized by an 
inflammatory process, which results in complete destruction 
of the hair papillae, and the formation of cicatricial tissue ; 
and by a tendency for its lesions to aggregate themselves in 
groups. Besnier 1 reported a case of this in 1889. He says that 
it is the same thing that has been called acne lupoide and 
folliculite epilante. In the case reported the disease affected 
all the posterior part of the scalp, which was sown over 
with disseminated patches of baldness of unequal size, 
irregular shape, and serpiginous. They were depressed in 
the center, which was smooth, polished, thinned, cicatricial, 

1 Annal. Derm, et Syph., 1889, x. 104. 



FOLLICULITIS DECALVANS. 253 

and completely bald. Their borders were not well defined, 
but merged into the islands of healthy hair. The scalp 
between the borders and the center of the patches was bald, 
of variegated redness, with some hairs broken off at the sur- 
face of the scalp. In the funnel-shaped openings of the 
hair follicles there were little superficial collections of pus. 
Some of the patches were torn by scratching, and others 
looked precisely like those of alopecia areata, without signs 
of inflammation. All treatment seemed to be in vain, and 
the scalp bore only the mildest applications. 

Another variety of folliculitis decalvans is that described 
by Quinquaud. It affects most often the scalp hair, more 
rarely that of the beard, pubes, and axillary region. It 
produces irregularly shaped areas of baldness, which are 
quite smooth, polished, pale, atrophic-looking, and present- 
ing at some points slight redness. The areas are dissemi- 
nated, about the size of a franc-piece, separated by islands 
of healthy hair. The bald spots are slightly depressed. At 
the peripheries of the patches or in the islands of healthy 
hair between them will be found pin-head, discrete pustules 
about the hairs. The latter are easily plucked or fall spon- 
taneously. Or we find simply punctiform, isolated, red 
spots which may or may not be scaly; or a red, elevated, 
inflamed follicle. The fall of neighboring hairs produces the 
bald patches. The disease is very chronic and marked by a 
series of outbreaks. A micrococcus has been found in 
probable causative connection with the disease. 

Still another form affects the bearded portion of the face 
and from there invades the temporal region of the scalp. 
This is the Ulerythema Sycosiforme of Unna, and the so- 
called chronic sycosis. It begins like a sycosis, but when the 
inflammation subsides it is seen that the skin is cicatricial and 
the hair destroyed. There may be one or more patches. The 
patches may be symmetrical or non-symmetrical, and they 
tend to spread slowly by peripheral extension. 

Treatment. The treatment found to be most efficacious 
is to clean the scalp with soap and water ; to paint the dis- 
eased patches and their vicinage with the tincture of iodine; 
and to bathe the same every morning With the following : 

12 



254 DISEASES OF THE SKIN. 

15 



R. 


Hydrarg. biniod., 


g 1 *- j ; 






Hydrarg. bichlor., 


gr. iv ; 


1 




Alcohol, 


.1 ss j 


60 




Aquse destil., 


ad % iv ; 


500 



M. 

This will check the disease, but the baldness is irremedi- 
able. (Brocq.) 

Folliculitis Rubra. See Keratosis pilaris. 

Fragilitas Crinium. See Atrophia pilorum propria. 

Frambcesia. See Yaws. 

Freckles. See Lentigo. 

Frieselausschlag. See Miliaria. 

Frostbite. See Dermatitis calorica. 

Fungous Foot of India. Synonyms : Madura foot ; 
Mycetoma ; Podelcoma ; Ulcus grave ; Tubercular disease 
of the foot. 

This is a disease that is endemic in certain parts of India, 
but has been met with in this country. Though usually 
affecting the foot and leg, it is seen occasionally on the 
hands, shoulders, and scrotum. According to Crocker, 
there are two varieties, the pale and the black, the latter 
being the more common. It may begin with slight conges- 
tion of the affected part; or as a local induration, either 
superficial or deeply seated, of some part of the foot, which 
is firmer, larger, more diffused, and less painful than a boil. 
When this is opened it discharges pus at first, later granules 
like poppy seeds, or mulberry-like masses are mingled with 
the discharge. Or it may begin as a blackish or bluish 
mottled discoloration like tatoo puncta. The progress of 
the disease is slow, but in the course of a few years the foot 
becomes swollen and distorted, the arch being broken, the 
toes being overextended, and the sole convex from behind 
forward. It becomes dotted over with the raised orifices of 
sinuses extending deep down into the tissues, and giving 
vent to the above-described discharge. 

It is more common in males than in females, and rare 
before puberty. Its origin is obscure, though it is supposed 



FURUNCULVS. 255 

to be due to a fungus. Surgical interference is the only 
hope for a cure. 

Furunculus (Fu^nrWku^-u^). Synonyms : (Fr.) Fur- 
oncle, Clou ; (Ger.) Blutschwar ; Furuncle or Boil. 

An acute circumscribed phlegmonous inflammation around 
a skin gland or follicle, characterized by one or more round, 
more or less acuminated, firm, painful formations, and 
usually terminating by necrosis and suppuration. (Foster.) 

Symptoms. This is a common and familiar disease of 
the skin. Its most frequent locations are the back of the 
neck, face, forearms, buttocks, and legs, though it may 
occur anywhere. It begins as a small, round, red, painful 
spot, which, in two or three days, enlarges to attain the size 
of a split-pea or silver quarter- or half-dollar. It is now 
raised above the surface, hard, of a dark-red color at the 
center with the redness fading away into the sound skin, 
more or less pyramidal in shape, exquisitely tender to the 
touch, and with a most agonizing throbbing pain. Its center 
soon becomes yellow, indicating the point at which sup- 
puration has taken place, and where it will open. From 
the opening comes the "core," a greenish-gray or whitish 
pultaceous mass mixed with pus and blood. With the es- 
cape of this, all the symptoms subside and the cavity fills 
up by granulation, leaving more or less of a scar. The 
course of the individual boil is from seven to ten or fifteen 
days. At times suppuration does not take place, but the 
mass undergoes resolution. This is the so-called " blind 
boil." 

There may be but one boil or there may be hundreds of 
them. They come out in crops of from two to half a dozen 
at a time. If very numerous, or of large size, they give 
rise to constitutional disturbance. They may continue to 
form for weeks, months, or even years, if left untreated. 
This is what is called furunculosis. 

Boils are always isolated. They may be confined to one 
spot or come out in a number of regions at the same time. 
There may be sympathetic enlargement of the neighboring 
lymphatics. If the disease is extensive, the patient presents 
a truly pitiable condition. 



256 DISEASES OF THE SKIN. 

If a boil starts from a sweat gland, it resembles that which 
originates in a sebaceous gland, except, according to Crocker, 
it has no mattery head and is somewhat less indurated. 
This form of boil is called " hydro-adenitis " by Verneuil 
and Bazin. It is of the size of a pea, and is most often 
met with in the axillae, about the anus and perineum, near 
the nipples, and may form anywhere where there are sweat 
glands, excepting on the soles of the feet. 

Boils may occur in the external auditory canal in con- 
junction with the disease elsewhere. They are exceedingly 
painful and produce deafness. One or both ears may be 
affected, but usually it is only one ear. They may set up 
inflammation of the entire canal and tympanum ; one case 
of this sort has ended fatally. If the furuncle is situated 
in the posterior wall of the canal, or a general inflammation 
has been set up, considerable redness and tumefaction over 
the mastoid region may occur. (Dr. A. Rupp. 1 ) 

Etiology. The cause of furuncles is believed to be the 
entrance into the skin of the staphylococcus pyogenes aureus 
et albus. It would certainly seem that local infection does 
play a part in the production of crops of boils occurring in 
one region, and the doctrine of local infection finds further 
support in the results of treatment by antiseptics. It must 
be remembered that these micrococci are widely distributed, 
having been found in dishwater, in the superficial layers of 
decayed vegetable matter, in the swaddling-clothes of healthy 
infants, in the dirt under the finger-nails, and in numerous 
other places. Like other parasites, these require some 
peculiarity of soil for their growth, or at least an opportu- 
nity for gaining entrance to the glandular apparatus of the 
skin. The soil is afforded in lowered vitality of the skin, 
and thus we find boils in diabetes mellitus, after specific 
fevers, in anaemia, lithaemia, uraemia, and septicaemia ; and 
as a complication of other skin diseases, such as eczema, 
prurigo, and scabies. In many cases no disorder of the 
general health can be discovered. The second condition is 
fulfilled by local injury to the skin, such as friction or pres- 

1 Personally communicated. 



FUBUNCULUS. 257 

sure, or scratching. It is probable that they are contagious, 
as they are certainly auto-inoculable, and can be produced 
by inoculation of pure cultures of the micrococcus. The 
popular notion of their origin from too good living is only 
another way of saying that they occur in individuals not in 
perfect health. 

Pathology. The inflammation begins in the corium 
and deeper tissues in or about the hair follicles or glands of 
the skin. " The mechanism of the process is supposed by 
some to be that the vessels around the gland or follicle be- 
come blocked, producing its death, and inflammation is then 
set up around the necrosed tissue to get rid of it by suppu- 
ration. ' ; (Crocker.) 

Diagnosis. The disease is so common that there is no 
need for detailing the diagnosis. For the diagnosis from 
carbuncle, see under that word. 

Treatment. In many cases there is no need of internal 
treatment. If the patient is out of health in any way, we 
should endeavor to help him back to his normal condition. 
In furunculosis we should always bear in mind the probability 
of there being diabetes mellitus at the bottom of the mis- 
chief, seek for it, and do our best to cure the patient if we 
find evidence of it. As a rule, tonics are called for. There 
are many drugs recommended for the treatment of boils, 
apart from constitutional conditions. Of these, sulphide of 
calciuui is one of the most popular, one-tenth of a grain 
being given every two or three hours, or a fourth to a half- 
grain three or four times a day. Piffard speaks well of the 
compound syrup of the hypophosphites, a dessertspoonful 
three times a day. Hardy recommends tar-water up to 
a quart a day. The sulphite or hyposulphite of sodium in 
fifteen- to twenty-grain dose three times a day is also well 
spoken of. Yeast is a homely but efficient remedy, either a 
half- win eglassful being taken night and morning, or a like 
quantity in divided doses, or one of Fleischmann's yeast 
cakes being eaten during the day. Le Gendre, 1 believing 
that boils may arise from the absorption of products of im- 

1 Union Med., 1888, xlv. 98. 



258 DISEASES OF THE SKIN. 

perfect digestion, advises the disinfection of the intestinal 
tract by the use of the following powder : 



R. /3-Naphtol, 

Bismuth, salicylat., \- aa gr. ivss 

Magnesia carb., 



30 

M. 



which is to be given every four hours. 

The local treatment of boils is important and efficient. 
They should not be poulticed, as, being due to a fungus, the 
heat and moisture only facilitate the growth of the same 
and the production of new boils. That new boils are apt to 
spring up about a poulticed boil is a common experience. 
" Hands off" is the rule for young boils, nor should old ones 
be squeezed. We should endeavor to abort the development 
of a boil. To do this there are various approved methods, 
but the one most highly commended is the use of carbolic 
acid. This may be either by touching them with pure car- 
bolic acid ; injecting them with a few drops of a two per 
cent, solution ; or spraying them with the same solution for 
fifteen minutes at a time eight times during the day, and 
keeping them covered with carbolized dressings in the 
meantime. Mercury may be used instead of carbolic acid, the 
boil being kept covered with emplastrum hydrarg. with a little 
hole cut in the plaster to correspond to the center of the boil ; 
or an ointment of the nitrate or red oxide may be used. 
Painting with iodine is also commended ; as well as keeping 
them covered with a saturated solution of boric acid, or an 
eight or ten per cent, plaster or ointment of salicylic acid. 
Hardaway speaks highly of Unna's carbolic acid and mer- 
cury mull plaster. Electrolysis to destroy the follicle is 
spoken of by the same authority. 

When aborting is out of the question, it is a good plan to 
thrust a little pure carbolic acid, on the sharpened end of a 
wooden toothpick or the like, into the central opening. It 
hurts for a few minutes only, and is promptly curative. The 
boil should then be dressed with carbolized vaseline or a boric 
acid ointment. Or it may be opened and dressed with 
iodoform, or aristol, as the odor of the former is objection- 
able. Here too the mull plaster of carbolic acid and mer- 



GERMAN MEASLES. 259 

cury may be used. Instead of the pure carbolic acid, 
Crocker advises the glycerole of carbolic acid of the British 
Pharmacopoeia. 

Furuncles of the ear. My friend, Dr. A. Rupp, late aural 
surgeon to the New York Eye and Ear Infirmary, has kindly 
advised me on this head as follows : If the auditory canal 
be filled or unclean, it must be syringed out with a two to 
five per cent, solution of carbolic acid followed by a solu- 
tion of bicarbonate of soda as hot as can be comfortably 
borne. 

The canal is to be dried with absorbent cotton, and if the 
membrana tympani is intact filled with. 

R. Hydrarg. bichlor., gr. v. 



Glycerini, ) aa -. m 

Alcoholis, J *3 ' 



30 



M. 



which is to remain in some minutes, and then the excess is 
allowed to drain off. The canal is lightly closed with 
borated or salicylated absorbent cotton. If the membrana 
tympani is deficient, the whole canal is to be filled with 
powdered boric acid, and the orifice closed as before. In 
either case the cotton is to be changed when soiled. When 
furuncles are at the inner end of the canal near the mem- 
brana tympani, a leech or two in front and a little above 
the tragus will afford much relief. It is unnecesary to incise 
the furuncles except where pus has formed and has no outlet. 
Prognosis. In most cases boils are annoying, but not 
dangerous. Those about the face give the most trouble. 
How long new boils will continue to form it is impossible to 
say. All will depend upon how soon we can get the patient 
into a better physical condition. 

Furunculus Orientalis. See Aleppo boil. 

Gale. See Scabies. 

Gangrene of the Skin. See Dermatitis gangrenosa. 

Gansehaut. See Cutis anserina. 

Gefassmal. See Nsevus vasculosus. 

German Measles. See Rubeola. 



260 DISEASES OF THE SKIN. 

Geromorphisme Cutane is the name chosen by Drs. 
Souques and Charcot 1 to designate an affection that pro- 
duced changes in the skin of a girl eleven years of age so 
that she looked like an old woman. The expression of the 
face suggested that due to facial paralysis. The skin hung 
in loose folds, and was flabby like the skin sometimes seen 
in very old people. Apart from loss of natural consistence 
and elasticity there was no change in the skin. If lifted 
up, twisted, or folded in any way, it returned very slowly to 
its normal position ; and it was abnormally movable over 
the subcutaneous tissues, in these things suggesting that 
form of dermatolysis called u elastic skin." There were no 
changes in the hair, nails, or teeth. There was no assign- 
able cause for the condition, which was preserved unaltered 
during an interval of ten years from the first to the last time 
that the doctors saw the case. 

Geschwulst is the German for tumor. 

Geschwiire. See Ulcers. 

Gesichtsatrophie. See Atrophoderma idiopathica. 

Glanders. See Equinia. 

Glanzhaut. See Atrophoderma idiopathica. 

Glossy Skin. See Atrophoderma idiopathica. 

Gneis. See Seborrhcea sicca. 

Gommes Scrofuleuses. See Scrofuloderma. 

Goose-flesh. See Cutis anserina. 

Granulationsgeschwulste (G-er.). Connective-tissue new 
growths. 

Granuloma. (Gra 2 n-u 2 l-o v ma 3 ). This is a tumor consist- 
ing of granulation tissue. " Proud flesh" is of this nature. 
It is seen about wounds, such as that caused by vaccination. 
It is probable that there is some specific germ to cause the 
growth of these exuberant granulations. It sometimes takes 
the form of a raspberry. The application of nitrate of silver 

1 Nouvelle Iconographie de la Salpetriere. 



G VINE A- WORM DISEASE. 261 

or tincture of iodine to it will cause it to flatten down 
speedily. 

Granuloma Fungoides. See Mycosis fungoides. 

Grayness. See Canities. 

Greisenhaftigheit der Kinder. See Sclerema neona- 
torum. 

Grocer's Itch is eczema of the hand. 

Grubs. See Comedo. 

Grutum. See Milium. 

Grutzgeschwulst. See Atheroma. 

Guinea-worm Disease or Dracontiasis is met with en- 
demically in tropical climates. It is caused by the larvae of 
the guinea-worm, or filaria medinensis, being swallowed, 
and developing in the body. The female makes its way 
into the muscles, and within nine to twelve months give rise 
to the symptoms of the disease. The male probably dies 
and is passed out of the body. The symptoms of the dis- 
ease are a small tumor under the skin that feels like a coil 
of soft string ; the appearance of a pea- to filbert-sized vesicle 
upon this when the animal is about to escape ; tension, 
pain, and itching ; in severe cases inflammation, purulent 
discharge, hectic fever, and perhaps delirium. The worm 
is either gradually wholly extruded after the vesicle breaks, 
or a new tumor forms after a part has escaped, and this after 
a time breaks and the rest of the worm comes away. There 
may be only one worm or a legion of them. They are 
located most often in the foot, but may be found anywhere. 

Treatment. The treatment of the disease is to remove 
the worm, which is done by winding it carefully around a 
stick when the head is protruded, giving a turn or two every 
day until the worm is extracted. Manson advises against 
this, and speaks well of injecting into the tumors a 1 to 
1000 solution of bichloride of mercury. This kills the 
worm, and it can then be removed. Tincture of asafoetida 
in doses of one or two drachms three times a day kills the 
worm before extraction. 

12* 



262 DISEASES OF THE SKIN. 

Gumma. See Syphilis. 

Gune. See Tinea imbricata. 

Gurtelkrankheit, See Zoster. 

Gutta Rosea. See Rosacea. 

Haarmenschen. See Hypertrichosis. 

Hsematidrosis (He 2 m-a 2 t-i 2 -dro / si 2 s) or Haemidrosis (He 2 m- 
i 2 -dro'-si 2 s) is a rare disease of the sweat glands in which, 
on account of an effusion of blood into the coils and their 
ducts by diapedesis from the surrounding vascular plexus, 
blood is discharged upon the skin along with the sweat. 
The subjects are apt to be hysterical young women, though 
the affection has been seen in newborn children. It is in 
some cases vicarious menstruation. The points of election 
are the face, ear, umbilicus, hands and feet. Ephidrosis 
cruenta and bleeding stigmata are other names for the curi- 
ous malady. The treatment should be directed to the con- 
dition of the individual. 

Hsemorrhoea Petechialis. See Purpura. 

Hair, Discolorations of. Hair sometimes falls out to grow 
in of a different color. The continuous hypodermatic ad- 
ministration of pilocarpine has been followed by a change of 
color of the hair from light to dark. Green hair occurs in 
workers in copper ; blue hair occurs in workers in cobalt and 
indigo. These colors can be removed by washing. Yellow 
hair is occasionally seen in icterus. Various chemicals 
bleach the hair, such as peroxide of hydrogen. Chrysa- 
robin stains it purple ; resorcin may stain it green. Bicar- 
bonate of soda changes dark hair to a dirty brown. 

Harlequin Foetus. See Ichthyosis congenita. 

Hautfinne. See Acne. 

Hauthorn. See Cornu cutaneum. 

Hautgries. See Milium. 

Hautkrebs. See Epithelioma. 

Hautsclerem. See Scleroderma. 



HERPES. 263 

Haemorrhage Cutaneous. See Purpura. 

Haematrophia Facialis. See Atrophoderma idiopathica. 

Herpes (Hu 5 r-pez). An acute inflammatory disease of 
the skin characterized by an eruption of one or more groups 
of vesicles upon reddened bases. 

There are two main varieties of the disease : one occur- 
ring upon the face, heroes facialis ; and one occurring upon 
the genitals, herpes progenitalis. 

Symptoms. Herpes facialis, also called herpes febrilis, 
herpes labialis, hydroa febrilis, fever blister or cold sore, 
usually occurs upon the lower part of the face, about the 
mouth (Fig. 31). There is commonly some slight disturb- 
ance of the general economy, not as part of the disease, but 
as the cause of it. The patient first notices more or less 
marked burning, stinging, or itching in the part, and per- 
haps at the same time erythematous papules may form. 
After a few hours a number of pin-head- to pea-sized, clear, 
fully distended vesicles will appear upon an erythematous 
base. Perhaps the herpetic patch may appear suddenly 
without antecedent erythema. There is usually not more 
than one or two patches of small size. There may be a 
score or more of them, and they may be of large size. The 
patches are always irregular in shape. There may be but 
two or three vesicles in a group, or there may be a dozen of 
them. They do not tend to break down of themselves, but 
after a few days dry up into a crust which falls and leaves a 
red spot that soon disappears. Sometimes the vesicles may 
coalesce into bullae, the covers of which may fall and a super- 
ficial ulceration be left. The duration of the disease is about 
eight or ten days. The most common location is upon the 
upper lip, but it may be anywhere upon the face, aod not 
uncommonly the groups develop bilaterally. The mucous 
membrane of the mouth may also be involved, but here, 
owing to the heat and moisture, the vesicles are seldom seen, 
as they break down and leave excoriated points. There is 
a strong tendency for the disease to recur with the recur- 
rence of the exciting cause. In some cases it recurs at ir- 
regular intervals for months and without apparent cause. 



264 



DISEASES OF THE SKIN. 



Etiology. It is still an undetermined question whether 
herpes facialis is a zoster or not. By most authorities it is 
considered to be an independent disease; by a few it is 
thought to be an incomplete zoster. It is known to occur 
with catarrhal inflammations of mucous membranes, such as 
a coryza or bronchitis ; with digestive derangement, as gas- 

FlG. 31. 




J* 



il <in ji.ii'^flfewi^f' 




Herpes febrilis. 

tritis or enteritis ; with various febrile diseases; and it is very 
often seen in women as a herald of the menstrual epoch, occur- 
ring with great regularity for years. It arises sometimes 
on account of an injury to the terminal ends of the nerves, 
and, as such injuries are liable to occur in the tender mucous 
membrane of the lips, this may be an explanation of its fre- 
quency about the mouth. Infection has been invoked by a 
few observers as a cause, but this is not proven. It is evi- 



HERPES, 265 

dently a neurosis. Sometimes it occurs coincidently with 
herpes progenitalis, or with zoster. 

Diagnosis. It must be diagnosticated from zoster and 
from vesicular eczema. From zoster it differs in not occur- 
ring in a series of groups scattered along the course of dis- 
tribution of the trigeminus ; and in frequently being bi- 
lateral. Generally speaking there is more marked neuralgia 
in zoster, though in some cases this is wanting. From eczema 
it differs in the large size of its vesicles, in their showing no 
tendency to break down, in being less pruriginous, in run- 
ning a regular course and rapidly recovering by the simple 
drying up of the vesicles. 

Treatment. Left to itself the disease will speedily get 
well, and really requires no treatment beyond protection 
with flexible collodion, or any indifferent soothing lotion or 
ointment. We are often asked if we cannot prevent or abort 
the disease when due to the menstrual flux. Women know 
well that the application of spirits of camphor will sometimes 
do this. Hardaway recommends rubbing the part with 
borax. Or one of the alcoholic solutions recommended by 
Leloir for this purpose in herpes progenitalis may be 
used, namely, either 2 per cent, resorcin ; 1 per cent, thy- 
mol ; 3 per cent, menthol, or 2 per cent, tannin frequently 
applied. 

Herpes progenitalis. This has been called herpes pre- 
putials, but as it occurs in women as well as men and on 
other places than the prepuce, that name is obviously incor- 
rect. 

Symptoms. The eruption is preceded and accompanied 
by burning and itching, and the vesicles occur in groups 
upon an erythematous base. If on the prepuce, that part 
is sometimes swollen. The vesicles are at first clear with 
serous contents, and if on moist locations, as under the pre- 
puce or about the mucous membranes of the female geni- 
tals, they soon break down and leave tiny excoriations. 
There may be but one or several patches of herpes. The 
disease runs a course of eight or ten days and gets well of 
itself, unless irritated under the mistaken idea of its being 
a chancroid. 



266 DISEASES OF THE SKIN. 

According to Bergh, 1 who has made a careful study of the 
disease, in women the groups usually contain five to eight 
pin-head to hemp-seed size vesicles, but may have twenty to 
thirty-five millet to poppy seed size vesicles. Around each 
group is a reddish areola. The vesicles are isolated, and 
seldom confluent. Itching is apt to precede their outbreak. 
There may also be slight tenderness or swelling of the 
neighboring glands. In both sexes the patches may be 
unilateral, bilateral, or median. In men it occurs most 
frequently on the inner surface of the prepuce, then on its 
outer surface, the sulcus, glans, meatus, sheath of the penis, 
and rarely in the meatus. In women, Bergh found it most 
often on the labia majora, then the labia minora, and ano- 
genital region ; seldom on the clitoris or in the vestibule ; 
very rarely on the cervix uteri. Unna 2 gives the order of 
frequency as labia minora, clitoris, labia majora, introitus 
vaginae et carunculae myrtiformes, perineum, anal region, 
genito-crural fold, mons veneris, and mucous membrane of 
anus and vagina. The disease has a tendency to relapse, 
in men with each coitus, in women with each menstrual 
period. It is very common in women to have herpes of the 
face at the same time, and this has been noted in men. 

Etiology. The cause of the disease is congestion of the 
genital region. Thus in men it is frequently seen two or 
three days after each coitus ; or accompanying a gonor- 
rhoea or chancre (soft sore). A long prepuce seems to pre- 
dispose to it. In women it comes in 80 per cent, of the 
cases with menstruation (Bergh), and in them it does not 
seem to have any marked relation to the sexual act. It is 
also seen in connection with pregnancy and the puerperal 
state. It is a not infrequent disease. Greenough 3 met 
with it in men in about 17 per cent, of all venereal cases in 
private practice. In women there are no statistics from 
private practice, and, indeed, it is in this country but rarely 
reported. Both Bergh and Unna, however, met with it 

1 Monatshefte f. prakt. Dermat., 1890, x. 1. 

2 Journ. Cutan. and Ven. Dis., 1883-4, i. 321. 

3 Archiv. Dermat., 1881, vii. 1. 



HERPES. 267 

very frequently in public prostitutes in St. Petersburg and 
Hamburg. 

Diagnosis. The disease of itself is of little moment, 
but is of great consequence viewed from a diagnostic stand- 
point on account of its liability to be taken for chancre (soft 
sore), or for the initial lesion of syphilis. This can hardly 
occur if the vesicles are seen, but when they are no longer 
present some difficulty may arise. From chancre the 
superficial character of the lesion points toward herpes. In 
case of doubt the use of a simple dusting-powder for a day 
or two will clear up the difficulty, because the chancre will 
continue to enlarge while the herpes will become well. 
Auto-inoculation will afford positive evidence. From the 
initial lesion of syphilis herpes differs in the absence of all 
induration of its base, and in the inflammatory character of 
the lesion. Here again a short wait will clear up the diag- 
nosis. 

Tkbatment. Herpes progenitalis will usually promptly 
disappear by the use of a dusting-powder of bismuth, or 
oxide of zinc and starch ; or by covering it with a piece of 
lint soaked in an astringent solution, such as a weak lotion 
of liquor plumbi subacetatis. If suppuration has occurred 
on account of bad treatment, and the glands are enlarged or 
tender, the patient had best be put in bed. Circumcision 
has been recommended to prevent recurrences, but is of 
doubtful efficacy. It is well to have the patient wash the 
parts daily, and after coitus. Marriage and fidelity to the 
wife are good means of curing a relapsing herpes. Astrin- 
gent washes are useful in both sexes. If the " habit" of 
herpes progenitalis, as it may be termed, has been formed, 
careful hygienic and general treatment may be necessary for 
a cure. Leloir's directions, as given under herpes facialis, 
may be tried for aborting the disease. 

Herpes Circinatus is either erythema iris or trichophy- 
tosis corporis. 

Herpes Circinatus Bullosus was the name given by Wilson 
to what has since been called Herpes gestationis. 

Herpes Cretace. See Lupus erythematosus. 



268 DISEASES OF THE SKIN. 

Herpes Esthiomenes. See Lupus vulgaris. 

Herpes Gestationis is regarded as being a dermatitis her- 
petiformis occurring during and provoked by pregnancy. 
It is prone to relapse with each succeeding pregnancy ; and 
slowly subsides after delivery. Apart from its etiological 
relation, it corresponds closely to dermatitis herpetiformis, 
which see. 

Herpes Imbrique. See Trichophytosis corporis. 

Herpes Iris. See Erythema Iris. 

Herpes Parasitaires. See Trichophytosis corporis. 

Herpes Phlyctsenoides. See Zoster. 

Herpes Tonsurans, seu Tonsurant. See Trichophytosis 
capitis. 

Herpes Tonsurans Muculosus. See Pityriasis rosea. 

Herpes Zoster. See Zoster. 

Herp 'tide Maligne Exfoliative. See Dermatitis ex- 
foliativa* 

Herpetide (E 2 r-pa-ted). This is a class of skin disease 
which depend upon what the French writers call the her- 
petic diathesis. The affections in this class are marked by 
long duration ; obstinancy to treatment ; tendency to re- 
lapse ; and more or less pain and discomfort. Under it are 
included eczema, the lichens, psoriasis, and prurigo. 

Hidrocystoma (Hi-dro'sist-o'ma 3 ). This disease was 
formerly regarded as a pompholyx of the face, but Robin- 
son 1 has shown that it is a separate affection. 

Symptoms. The eruption occurs upon the face in the 
form of a large number of discrete, disseminated, tense, clear, 
watery, boiled sago-grain-like vesicles. In size they vary 
from that of a pin-head to that of a pea. In color they may 
be light yellow, of a bluish tint, or white. If pricked, a drop 
of clear acid fluid escapes. They are obtuse, round, or ovoid. 
If they are present in immense numbers, they may crowd 

1 Journ. Cutan. and Gen.-urin. Dis., 1893, xi. 293. 



HIDR0CY6T0MA. 



269 



closely together, but do not coalesce. There is no sign of 
inflammation about them, and no subjective symptoms arise 
from them, excepting, at times, a feeling of tension or smart- 
ing that is not pronounced. After lasting several weeks 
they dry up and disappear, while new ones appear. 



Fig. 32. 




The eruption is usually seen upon the lower part of the 
forehead, the orbital region, nose, cheeks, lips and chin, that 
is, upon the middle regions of the face. 

Etiology. Mostf cases occur in women, and especially in 
washerwomen. It is worse in summer, often disappearing 



270 DISEASES OF THE SKIX. 

entirely in winter, to return in the following summer. It 
is a disease of adult life. 

Pathology. The secreting portion of some of the sweat 
glands have an enlarged lumen from dilatation of the tube 
and contraction or compression of the epithelial cells against 
the basement-membrane, the lumen being filled with liquid, 
and a granular material resembling that usually seen in 
normal glands, but in increased amount. With the excep- 
tions of those thus affected, the excretory apparatus wa3 
normal. (Robinson.) 

Treatment. As far as possible the patient must avoid 
everything that will cause sweating. The individual lesions 
must be punctured. 

Hirsuties. See Hypertrichosis. 

Hives. See Urticaria. 

Homines Pilosi. See Hypertrichosis. 

Homines Sylvestris. See Hypertrichosis. 

Honeycomb Ringworm. See Favus. 

Horn. See Cornua cutaneum. 

Huhnerauge. See Clavus. 

Hyalome Cutane. See Colloid degeneration of the skin. 

Hydradenomes Eruptifs. See Adenoma of sweat glands. 

Hydroa (Hi-dro'-a 3 ) is practically dermatitis herpetiformis. 
It is an old term recently revived, and is of uncertain sig- 
nificance. By some it is used to designate eruptions that 
are midway between erythema multiforme and pemphigus. 
As dermatitis herpetiformis certainly comprises what has 
been described as hydroa, I shall consider the latter no 
further. 

Hydroa Bulleux. See Erythema iris. 

Hydroa Vacciniforme. Hutchinson, under the name of 
" Recurrent Summer Eruption/' Unna, under the name of 
"Hydroa Puerorum," and Bazin, under the name at the 
head of this section, have described a bullous disease that 



HYPERESTHESIA. 271 

occurs mostly in boys- and upon exposed parts. It usually 
occurs in summer and then seems to be due to the heat of 
the sun. It may occur in winter and be due to the action 
of high winds. The bullae form as such or as the result of 
the confluence of vesicles, and commonly both vesicles and 
bullae are present at the same time. The vesicles are prone 
to become depressed in the centre and resemble vaccine 
scars. Scarring is apt to result. The disease recurs from 
time to time and tends to cease altogether as puberty is 
reached. The disease is related clinically to bullous ery- 
thema and to dermatitis herpetiformis, though it differs from 
them in leaving scars. Bowen has shown that it is inflam- 
matory in origin. 

Hydro- adenitis. See Furunculus of sweat glands. 

Hygroma Cysticum Colli Congenitum. See Lymphan- 
gioma. 

Hyperaesthesia (Hip-uVeVthe'-zrW). This is that con- 
dition of the skin in which pain is experienced on the slightest 
contact even of a current of air, in this differing from der- 
matalgia, in which the pain is spontaneous. It is a neurotic 
disease and is met with most commonly as a symptom of 
other diseases, such as non-tuberculated leprosy, hydro- 
phobia, and hysteria. Idiopathic cases are met with, though 
rarely. The hyperaesthesia may be general or localized, 
unilateral or symmetrical. 

The treatment is in most cases that of the disease of which 
it is but a symptom. Barbillion 1 cured one case of the idio- 
pathic variety by blisters, and two cases be congelation by 
means of methyl chloride. It is probable that cataphoresis 
by cocaine after the method of Peterson might by beneficial. 
This is done by means of disks of filter-paper soaked in 
cocaine, and placed on a specially made electrode attached to 
the positive pole of a galvanic battery. The sponge electrode 
attached to the negative pole is placed indifferently on the 
skin, and a current of some five milliampeires, if the patient 
can bear so much, is allowed to pass for fifteen or twenty 
minutes. 

1 Progres Med., 1885, i. 375. 



272 DISEASES OF THE SKIN. 

Hyperidrosis (Hip-u 5 r-i 2 d-ro'si 2 s). Synonyms : Ephidro- 
sis ; Idrosis ; Sudatoria ; Polyidrosis ; Excessive Sweating. 

A functional disorder of the sweat glands characterized 
by an excessive flow of sweat. 

Symptoms. Hyperidrosis may be general or localized : 
unilateral ; or symmetrical ; in large or small amount. 
The cases of general sweating occur most often sympto- 
matically in the course of general diseases, such as phthisis, 
malaria, and rheumatism, and do not concern us now. 
Some cases occur idiopathically. Such patients are usually 
fat. The hyperidrosis may be constant or at intervals, being 
excited by the slightest irritation of the nervous system, or 
by muscular exertion. The outburst of the sweat is gen- 
erally preceded by a prickling sensation. It is apt to be 
accompanied by prickly heat (lichen tropicus). 

We are called upon as dermatologists to treat localized 
sweating more often than the just-described variety, and 
such cases occur most commonly upon the palms and soles, 
in the axillae, about the genitals, and on the face and scalp. 
The excessive flow of sweat may be constant, but it is usu- 
ally paroxysmal, and often under the influence of the emo- 
tions. It is usually more pronounced in warm than in cold 
weather. Fat people are more prone to it than are 
those who are thin ; anaemic and delicate people rather 
than the robust. In some cases there may be a sense of 
tingling before the flow occurs. The aifected part may be 
warm or cold ; if the first, it is apt to be somewhat hyperae- 
mic. Occurring in places that are warm and covered, 
bromidrosis is a common accompaniment. The disease may 
last for years. 

Sweating palms usually feel cold and clammy. Some- 
times the amount of sweat is only enough to keep them 
more or less constantly moist ; sometimes it is so abundant 
as to drop from the hands and fingers, or even to fill up 
the upturned palm and run over the edge. It spoils gloves, 
and interferes with many forms of work. Sweating soles'are 
soon followed by tender feet, the epidermis becoming sod- 
den, macerated, and removed. It interferes with walking. 
The edge of the foot just about the soles appears as a white 



HYPERIDROSIS. 273 

or gray line or seam of sodden epidermis with a pinkish 
seam above it. The sodden appearance is also well marked 
between the toes. Sweating in the axillae spoils the cloth- 
ing, and is only rendered worse by the rubber dress-shields 
so commonly worn by women. In its paroxysmal form it is 
frequently encountered in patients stripped for examination 
in public. This form has been aptly named by the French 
the "military SAveat," as it is seen so often in examining re- 
cruits for the army. Sweating about the genitals is often 
accompanied by intertrigo, which may also occur in other 
parts subject to hyperidrosis where folds of skin are in con- 
tact. Sweating of the face is most commonly encountered 
upon the forehead, nose, and eyelids, beads of sweat stand- 
ing out upon them or running off in little rivulets. It is 
here that hsemidrosis is most common. Upon the scalp it 
has been observed that its occurrence is frequently followed 
by loss of hair. 

Unilateral sweating is occasionally met with. It may 
affect half of the forehead or face, or whole body. Upon 
the forehead and face this form of sweating occurs as an 
accompaniment of migraine and limited to the painful re- 
gion ; it is in paraplegia that one-half of the body alone is 
affected. 

Etiology. The disease is probably due to a disturbance 
in the sphere of the sympathetic system. It has followed 
lesions of the cerebro-spinal nerves. It occurs in all classes 
and conditions of men, and in all ages and both sexes. In 
some cases it is hereditary. Ill health seems to be the 
cause in many cases ; it may be anaemia ; chlorosis ; lith- 
aemia ; hysteria ; or general debility. In any case it is 
purely a functional disease of the sweat glands, they being 
structurally unchanged. 

The diagnosis is so evident that we need not stop to dif- 
ferentiate it systematically. 

Treatment. The condition of the patient's health is to 
be carefully investigated, and tonics, mineral acids, nux 
vomica, or other medicine ordered according to the nature 
of the case. If there is no indication for this plan, or it 
does not succeed, recourse may be had to belladonna or 



Be . Pulv. cretse co., 


3iij; 


25 


Pulv. ciimam. co., 


3y; 


15 


Sulph. prsecip. , 


Zy, 


100 


Sig. A teaspoonful twice a day. 







274 DISEASES OF THE SKIN. 

atropia to the point of producing their full physiological 
effect ; or pilocarpine, -^ gr. t. i. d. ; or agaricin in dose 
of \ gr. ; or ergot, half a drachm of the fluid extract t. i. d. 
Crocker has found a full teaspoon of precipitated sulphur 
in milk twice a day the best remedy. If it loosens the 
bowels too much, he prescribes it as follows : 



M. 



The local treatment in many cases is as unsatisfactory as 
the constitutional treatment. There have been many plans 
proposed. Local faradization is one agent. Very hot water 
may be sponged on for a few minutes ; belladonna ointment 
or liniment may be rubbed in ; or we may use some astrin- 
gent application, as of bismuth, tannin, alum, sulphate of 
zinc, borax, and the like, in alcohol, ointment, or powder. 
As a rule, ointments cannot be used on the hands and face. 
The strength of the alcoholic solution is 1 to 3 per cent. 
The most reliable of these is probably a saturated solution 
of boric acid, or a 3 per cent, solution of salicylic acid. 
Kaposi speaks highly of the good effect of bathing the parts 
with a 5 per cent, solution of naphthol in alcohol, and keep- 
ing them powdered with one part of naphthol to one hun- 
dred of starch. Piffard recommends freshly prepared silicic 
hydrate, one part, in ointment of rose-water, nine parts. 
Sulphate of quinine, 5 per cent, in alcohol, may be tried. 
For sweating of the feet the best means are those given 
under Bromidrosis, which see. Permanganate of potash in 
1 per cent, strength may be used. Unna recommends 
ichthyol in 2J per cent, ointment and the use of ichthyol 
soap. 

The prognosis is doubtful, many cases proving very 
rebellious to treatment. 

Hyperkeratosis excentrica. See Porokeratosis. 

Hypertrichosis (Hip-e^-trik-ho'-srV). Synonyms : Hir- 
suties ; Trichauxis ; Polytrichia ; Dasyma ; Trichosis hir- 
suties ; (Fr.) Poils accidentels ; Superfluous hair. 



HYPERTRICHOSIS. 275 

Symptoms. Hypertrichosis is a growth of hair that is 
either abnormal in amount or occurs in places where, nor- 
mally, only lanugo hairs are present. It may be general 
or partial, congenital or acquired. The general form is also 
congenital, but it is never universal, as no hair grows upon 
the palms and soles, the backs of the last phalanges of the 
fingers and toes, the inside of the labia majora, the prepuce, 
and glans penis. Subjects of this malady are usually born 
covered more or less thickly with hair, which may be light 
or dark in color. This continues growing longer, coarser, 
and darker till it reaches its full development. As a rule, 
the long hair covering the body is fine, resembling more the 
hair of the head than of the beard, as is also the case with 
the hair on the face of these people. With this excessive 
growth of hair there is usually combined a deficiency of 
teeth, specially marked in the upper jaw. Subjects of this 
malady are called homines pilosi and are met with in all 
quarters of the w 7 orld. 

Of partial congenital hypertrichosis we have an immense 
number of examples. This condition is apt to be of the 
nature of nsevus. The distinction between a localized 
hypertrichosis and a naevus is made mostly upon the color 
of the underlying skin. In the former case the skin is per- 
fectly normal, while in the latter it is pigmented and may be 
otherwise altered. Thus we have in the Lancet of 1869, ii. 
27 6, an account of a Mexican woman who had a naevus pilosus 
extending, like a pair of bathing trousers, from the umbilicus 
anteriorly and the sixth dorsal vertebra posteriorly, to about 
half-way down the thighs, covering the buttocks Dr. 
Cummin 1 mentions the case of a lady who was noted for the 
beauty of her face, whose body from breast to knee was 
covered with a profusion of black, thick, bristly hair. Wal- 
deyer 2 reports the case of a girl, nine years of age, who had 
a lock of hair running from the first to the fourth lumbar 
vertebra, and a smaller one from the third to the fourth cer- 
vical vertebra. These localized and partial cases of hyper- 

1 London Medical Gazette, 1836, xix. 263. 

2 Atlas der menschl. u. thierisch. Haare. Lahr, 1884. 



'276 DISEASES OF THE SKIN. 

trichosis are most frequently met with in the sacral or 
lumbar region, and not infrequently are associated with 
spina bifida. 

Partial acquired hypertrichosis is more common than is 
the congenital variety, and takes the form either of an ex- 
cessive growth of hair in regions where it is usually found, 
or of the development of hair in regions usually hairless or 
only provided with downy or lanugo hair, or of the develop- 
ment of pubertal hair at an early age. 

The following cases are instances of excessive growth and 
precocious development. Chowne 1 speaks of a boy, eight 
years of age, who had the whiskers of a man. Beigel 2 has 
seen a six-year-old girl with pudenda like a twenty-year- 
old woman, both in shape and hair. A case of excessive 
growth was met with by Leonard 3 in a man in his neighbor- 
hood whose beard measured seven feet six and a half inches 
in length. Other instances of excessive length of beard 
are found in medical literature. 4 Many men have an excess 
of hair upon the chest and shoulders. Hair is generally better 
developed upon the forearm than upon the upper arm, and 
upon the legs than upon the thighs. As men grow old they 
are apt to have long hairs grow from the nostrils and the 
ears. These are instances of the growth of strong hair 
where normally only lanugo hairs are present. 

The growth of the beard in women is the form of hyper- 
trichosis which concerns us most, as it is the deformity which 
we will be called upon to cure. As women grow old, espe- 
cially after they have passed through the climacteric period 
of middle life, a slight mustache or a few straggling dark 
hairs on other parts of the face often appear. These growths 
seldom annoy them much, as they are accepted as evidences 
of advancing years. The case is very different when a 
young woman is afflicted with a beard, and most of the 
patients who apply for relief from their facial hair are between 
twenty and thirty-five years old. In them the hair gene- 

1 Lancet, 1852, i. 421. 

2 Virchow's Archiv, 1868, xliv. 418. 

3 The Hair: its Diseases and Treatment. Detroit, 1881. 

4 Jackson : Diseases of the Hair and Scalp. New York, 1887. 



HYPERTRICHOSIS. 277 

rally begins to grow so as to be noticeable at about the 
eighteenth year of age. To get rid of the trouble the 
tweezers are first resorted to ; then depilatories are tried ; 
sometimes burning is attempted, and as a final refuge the 
razor is used. All the time the hair grows coarser and 
more abundant. Some of these women shun company, 
keep themselves shut up all day, their health deteriorates, 
and, constantly brooding over their misfortune, they are 
prone to become hypochondriacal and melancholic. The 
amount of hair presented by these cases varies. Perhaps 
the commonest growth is the mustache alone. In most of 
my cases the hair has grown thickest and coarsest under 
the chin and upon the front of the throat. It is rare, even 
in the best-developed cases, to have much hair under the 
lower lip. Sometimes the growth is as complete, as heavy, 
and as coarse as is met with in men. The skin of many 
cases is coarse, muddy, greasy, and studded with acne. 

From time to time cases of transitory hypertrichosis 
have been reported. This has been noticed during the 
treatment of a fractured limb, the hair being much more 
prominent upon the part that has been kept quiet and warm. 
In some of these cases the increase is probably more apparent 
than real, the hair not having been rubbed off by friction. 
Likewise, after injury to nerves the hair sometimes becomes 
hypertrophied, only to fall out after recovery. Continued 
irritation of a part, as by blisters, may stimulate hair- 
growth which may or may not be transitory. The most 
interesting of this group of cases is that comprising those 
of hirsuties occurring during pregnancy, and disappearing 
again after some months. Wilson reported a case of delayed 
appearance of menstruation in which hair grew upon the 
face. After the menstrual function was established the 
hair ceased to grow and gradually disappeared. 

Etiology. The cause of hypertrichosis is very obscure 
in some of its forms, while in other varieties we can more 
readily discover it. In general congenital hirsuties heredity 
plays an important part. But hereditary tendencies will 
not explain the first appearance of these congenital cases. 
Virchow endeavored to account for them upon the theory of 

13 



278 DISEASES OF THE SKIN. 

nervous influence, founded upon the fact that in the Kos- 
troma people the lack of development of the teeth and jaws 
was in the same zone as the over-development of the hair 
on the forehead, nose, cheek, and ears ; these regions all 
being supplied by branches of the trigeminus or fifth cra- 
nial nerve. Unna's theory of congenital hypertrichosis is 
that it is due to a persistence of the foetal or primitive hair ; 
the change of type between the primitive and permanent 
hair not taking place. 

The cause of acquired hirsuties is, in some cases, not far 
to seek. Heat and moisture will apparently increase the 
growth of hair, just as they favor the growth of vegetable 
life. Thus the hair has grown luxuriantly under the stimu- 
lation of poultices, and on the limbs when confined in a 
fracture-box. To these factors must be added an increase 
of the flow of blood to the part. Increase of the flow of 
blood will stimulate hair-growth independently of heat and 
moisture. At least Prentiss's case of hair growing more 
luxuriantly and coarser under the use of pilocarpine, which 
causes hyperemia of the skin, would seem to indicate this, 
Hypertrichosis following injury to nerves is probably de- 
pendent upon vasomotor disturbances. The growth of hair 
upon exposed parts, as upon the arms and chest of laboring- 
men, sailors, and the like, is due to the local irritation of the 
sun and wind. 

Now we come to the more obscure cause of facial hirsu- 
ties in women. To account for this, numerous hypotheses 
have been formed. Probably the one most generally 
accepted is that it is in some way connected with derange- 
ment of the uterus and appendages. Because in some 
bearded women there has been some evident derangement 
of the sexual organs, it has been affirmed that some similar 
derangement is present in all. This is on a par with the 
too loosely accepted idea that too free use of alcohol is the 
only cause of rosacea. In the cases I have met with, the 
majority were as free from uterine trouble as the rest of their 
sex. While it is true that some of these women are of mas- 
culine build, and have a masculine voice, most of them do 
not exhibit these characteristics. In some cases, however, 



HYPERTRICHOSIS. 279 

there does seem to be some relation between the reproduc- 
tive organs and the growth of the beard. Heredity is often 
well marked. It is improbable that attempts at destroying 
the fine hair causes the development of the coarse hair. It 
is more likely that it only strengthens its growth. 

An interesting study of the relation between hirsuties in 
women and insanity was made by Hamilton. 1 He regards 
hair-growth on the face in women as the inevitable result of 
the overactive and continuous exercise of the uterine and 
ovarian functions. He believes it to be of neuropathic 
origin, connected with disorders of the fifth cranial nerve; 
and that when it occurs upon the face of an insane person 
it is indicative of an unfavorable form of insanity, especially 
if the subject has not reached middle life. 

We may sum up the evidence on the etiology of facial 
hirsuties in this way : While at times there appears to be a 
relation between the uterine, or, more properly, the menstrual 
function, and the growth of hair on the face, shown by a 
decrease or deficiency of the first, and an increase of the 
second, still in the majority of cases no such relation is 
discoverable, and it must be viewed as a deformity, or a freak 
of Nature, or as a matter of inheritance. 

Teeatment. For general hypertrichosis we can practi- 
cally do nothing. This, not because we cannot destroy hair 
so that it will not grow again, but because of the great 
amount of time it would take to destroy it. 

The only form of hirsuties which urgently calls for relief 
is that occurring upon the face of women. In 1875 Dr. 
Michel, of St. Louis, devised the method of removing the 
hairs in trichiasis by means of electrolysis, which was taken 
up by Dr. Hardaway, of the same city, for the removal of 
superfluous hair. The question is often asked : Is the 
removal, by this method, permanent ? " This question may 
be answered, " It is, without a shadow of a doubt." The 
object being to destroy the papilla, and that being very 
small and often placed at an unexpected angle to the sur- 
face of the skin, it is not possible always to accomplish this 

1 The Medical Kecord, 1881, xix. 281. 



280 DISEASES OF THE SKIN. 

at the first attempt ; but with patience and the necessary 
skill, it will finally be permanently destroyed. At times, 
after the dark, coarse hairs have been removed, there will be 
found a number of finer and lighter hairs. This appear- 
ance is due partly to the uncovering of these hairs, and 
partly, it may be, to lanugo hairs becoming stronger under 
the stimulation of the operation. In most cases, with 
proper care and the use of a fine needle, the amount of scar- 
ring will be very slight, amounting to nothing more than 
fine punctate cicatricial spots. In some peculiarly irri- 
table skins it is very difficult to prevent the formation of 
plainly visible scars. The upper lip is also prone to scar- 
ring. If the proper conditions are not observed, the 
operator must expect to produce a good deal of disfigure- 
ment. 

The amount of pain experienced by the patient will vary 
greatly. Certain parts of the face are far more sensitive 
than others. On the whole, the pain does not amount to 
much. After a time the skin seems to become tolerant of 
the action of the current and the patient no longer com- 
plains. Hyper-pigmentation may be produced by the oper- 
ation. This is a very rare complication, and is only men- 
tioned by way of warning. 

The instruments needed for the operation are a good 
twenty-cell zinc-carbon (galvanic) battery, a sponge elec- 
trode, a proper needle-holder, a fine needle, a pair of epilating- 
forceps, and, if the operator's eyes are not good, a lens of 
low power. Any sponge electrode will answer. There are 
various patterns of needle-holders, any one of which may 
be used. It should be long enough to be held with ease, 
and not too long to be readily manipulated. The most 
essential instrument is the needle. Hardaway recommends 
a needle made of iridium and platinum. He claims that it 
will follow the direction of the hair follicle, and more surely 
hit the papilla than will a steel needle. I have had most 
satisfactory results with a jeweller's instrument called a 
" steel broach." These come in many grades ; those known 
as Nos. 5 and 7 are serviceable ones. A lens is generally 
not needed. Dr. Piffard has invented a needle-holder with 



HYPERTRICHOSIS. 281 

lens-attachment, which he has found useful. A galvan- 
ometer is not essential, but very desirable. 

A good light is necessary for the operation, and a cloudy 
day is a bad one for working. An operating or reclining 
chair is a comfort, and the patient should be so placed that 
the part to be operated on is on a level with the operator's 
eye. The operation is done in the following manner : The 
patient, being in position, is to be given the sponge elec- 
trode attached to the positive pole of the battery, and told to 
hold it in one hand. The hair to be extracted is then 
seized with the forceps, and put slightly on the stretch in 
the direction in which it naturally grows. The needle, 
attached to the negative j>ole, is then inserted parallel 
with the hair and into the follicle. One soon learns to know 
whether the follicle is entered or not by the sense of touch. 
When the follicle is entered the needle glides along 
smoothly ; when it is not entered a sense of resistance is 
communicated to the fingers as the skin is punctured. The 
depth to which the needle is to be thrust will vary with the 
case. Roughly speaking, it is from ^ to -f^ of an inch. 
The needle being inserted, the patient is told to place the 
palm of the disengaged hand over the sponge electrode. In 
a few moments there will be frothing about the needle, and 
in from half a minute to a minute or more the hair will come 
away upon the very slightest traction. The hand is to be 
removed from the sponge before the needle is withdrawn 
from the follicle. 

The hair must not be pulled on with any force, for the 
ease with which it leaves the follicle is a guarantee of the 
completeness of the operation. The hairs must not be 
extracted in close proximity, because the inflammatory action 
thus set up will lead to more or less deep ulceration and 
subsequent prominent scars. Tt is best to extract only the 
coarser hair and to leave the lanugo hairs alone. The 
strength of the current to be used will depend upon the 
quality of the patient's skin and the recentness of the fill- 
ing of the battery. Six cells are the fewest I have used, 
and fifteen the greatest number. More exactly, a current- 
strength of J to 1 J milliamperes. 



282 DISEASES OF THE SKIN. 

The patient should be directed to bathe the face in hot 
water and to anoint it with cold cream several times during 
the day following the operation. 

Hypohydrosis. See Anidrosis. 

Hystricismus. See Ichthyosis. 

Ichthyosis (Fk-thi 2 -o'si 2 s). Synonyms : Xeroderma ; 
Xeroderma ichthyoides ; Icthyosis vera, seu congenita ; 
Sauriasis; (Fr.) Ichthyose ; (Ger.) Fischschuppenausschlag ; 
Fish-skin disease. 

Ichthyosis is a congenital, general or partial, chronic 
disease of the skin, characterized by dryness, harshness, and 
scaling of the skin, and sometimes by the development of 
warty-looking growths. 

Symptoms. Though the disease is congenital it usually 
does not show itself until after the second month, and some- 
times not until the second year. There are four varieties 
of the disease, namely : xeroderma, ichthyosis simplex, 
ichthyosis hystrix, and ichthyosis congenita. 

Xeroderma is the mildest grade of the disease. The skin 
is dry, harsh, slightly scaly, grayish or dirty-looking, and 
its natural lines are more pronounced than usual. Upon 
the extensor surfaces of the limbs it is particularly marked, 
and here too it is accompanied by keratosis pilaris. It is 
most annoying to young women who want to wear short- 
sleeved dresses. It is doubtless far more common than 
statistics show, as it very often is very slight in amount. 

Ichthyosis simplex. This is a more severe grade of the 
disease in which the skin is dry, harsh, and scaly, and also 
divided off into small diamond-shaped or polygonal figures 
(Fig. 33). While the whole cutaneous surface may be 
involved, the disease is usually most pronounced upon the 
extensor surfaces of the legs and arms. The face, scalp, 
palms, and soles are often spared. The skin about the 
extensor surfaces of the elbows and knees is generally 
thrown into well-marked folds, while the flexor surfaces of 
the same joints are unaffected, the skin in these situations 
being soft and natural. While upon the extremities the 



ICHTHYOSIS. 



283 



disease is well developed, upon the trunk it may assume 
more of the xerodermatous form. When the face and scalp 
are affected they are simply very scaly, while on the palms 
and soles we have accentuation of the normal lines. In a 
typical case the skin, especially of the extremities, will be 
grayish, greenish, or blackish-green in color, dry, and the 



Fig. 33. 










Ichthyosis. 

little polygonal plates will be attached in their centers and 
turned up slightly at their edges, so that they appear de- 
pressed in the centers. The amount of loose scaling is 
sometimes abundant, but usually moderate in amount. The 
hair, if the scalp is involved, is dry. The nails are often 
pitted. Ectropion may result in those rare cases in which 



284 DISEASES OF THE SKIN. 

the disease affects the face severely. Itching is often com- 
plained of, and eczema may complicate matters. There is 
a marked absence of perspiration, and lessened sebaceous 
secretion ; and the patients are sensitive to cold. The dis- 
ease is usually worse in cold weather. 

Ichthyosis hystrix is one of the rarest forms of the dis- 
ease. It is never general, but confined to a limited area, 
or to a number of areas. It is often unilateral, and at 
times seems to follow the course of a nerve in its distribu- 
tion. It occurs in the form of horny papillary growths, 
that maybe isolated and pin-point-sized; or massed together 
into elevated, warty, dark-green plates, traversed by deep 
lines ; or arranged in long lines of parallel rows. When in 
the last form it has been called nerve naevus, nsevus verru- 
cosus, neuropathic papilloma, papilloma neuroticum, and 
the like. Ichthyosis hystrix may be present alone, the rest 
of the skin being normal, or it may occur as a part of ich- 
thyosis simplex. 

Ichthyosis congenita is the most rare form of the disease. 
It is also called Keratoma follicularis, Keratosis diffusa, seu 
epidermica, seu intra-uterina, and the " Harlequin foetus/' 
It is considered by some to be a general seborrhoea. It is 
present at birth, the skin being covered with fatty epidermic 
plates cracked in all directions and arranged transversely to 
the axis of the body. The fissures may extend into the 
corium. The eyes are held partly open, or there may be 
ectropion ; the lips cannot be moved ; and the feet are con- 
tracted and deformed. The color is yellowish-white or 
grayish. The scrotum and penis may not be involved. 
These infants are either born dead or survive birth but a 
short time. 

There are also cases of ichthyosis intra-uterina in which, 
after the removal of the vernix caseosa, the skin looks red, 
glazed, and dry, and then soon assumes the characteristics 
of ichthyosis simplex. 

With the exception of ichthyosis congenita, the disease 
does not show itself until some months after birth, but by 
the second year it has made its appearance. As a rule, it 



ICHTHYOSIS. 285 

increases in severity as the patient grows older, until adult 
age, when it usually remains stationary, or perhaps improves 
a little. It is a chronic disease and shows no tendency to 
get well. It does not seem to affect the patient's health, 
and it should be regarded rather as a deformity than a dis- 
ease. Occasionally mental weakness and other congenital 
defects have been noticed. 

Etiology. We know of no cause for the disease beyond 
heredity, which may be direct, skip a generation, or be 
through a lateral branch. Many cases occur without mani- 
fest heredity. It attacks both sexes about equally. It shows 
a tendency to occur only in one sex in certain families, 
while in other families both sexes are equally affected. It 
is a congenital defect in the development of the skin with 
a disturbance of the functions of perspiration and sebaceous 
secretions. 

Diagnosis. The disease is so unique that if its charac- 
teristics are remembered there can be no difficulty in diag- 
nosis. There is no other disease commencing in infancy 
that at all corresponds to ichthyosis simplex. Xeroderma 
may resemble a mild grade of squamous eczema, but has 
not its history. Sometimes we meet with a dry skin that 
is not ichthyosis, but is only a passing state and has not 
existed from infancy. Ichthyosis hystrix may resemble 
common warts, and sometimes the latter may be present, 
but differs from them in its color and distribution. Ichthy- 
osis congenita differs from seborrhcea in not being removable 
by soaking in oil ; and by proving fatal. 

Tkeatment. The treatment is largely palliative. The 
free use of Russian baths or of prolonged warm baths, 
simple or with soda, and washing with soap, followed by 
inunctions of vaseline, glycerin, lanolin, or oil, such as cocoa- 
butter, will keep the skin supple. Kaposi recommends a 5 
per cent, naphthol ointment, or a 2 per cent, solution in 
spiritus sapo. viridis, or cod-liver oil, in conjunction with 
naphthol soap. Andeer 1 recommends a 3 to 20 per cent, 
ointment of resorcin well rubbed in, and covered with a 

1 Monatshefte f. prakt. Dermat., 1884, iii. 365. 
13* 



286 DISEASES OF THE SKIN. 

bandage, and claims a cure in eight days. Sulphur oint- 
ment has also been recommended. The daily application 
of half an ounce to an ounce of glycerin in a pint of water 
sometimes proves helpful. Whatever is used must be per- 
sisted in. Ichthyosis hystrix may be removed by curetting, 
or by salicylic acid plaster, 20 per cent, strength ; or by the 
same drug in alcohol or collodion, a drachm to the ounce. 

Besnier recommends, as adjuvants to the local treatment, 
regular gymnastic exercise and the internal administration 
of cod-liver oil. 

Prognosis. The prognosis is good as to life, bad as to 
cure. Thus far it has proved incurable in the hands of 
most physicians. All one can hope to accomplish is to 
render the patient comfortable and fit to mingle with his 
kind by repeated courses of treatment. Ichthyosis con- 
genita is fatal in a few days, if the child is not born dead, 
as is usually the case. 

Ichthyosis Follicularis. See Keratosis follicularis. 

Ichthyosis Sebacea. See Seborrhcea sicca. 

Idrosis. See Hyperidrosis. 

Ignis Sacer. See Zoster. 

Impetigo (I 2 m-pe 2 t-i r go) is a name that was applied at 
one time to all pustular eruptions. At the present time 
there are but three varieties described, namely : Impetigo 
or impetigo simplex ; Impetigo contagiosa ; and Impetigo 
herpetiformis. The right of the first-named variety to be 
recognized as a distinct affection is denied by systematic 
writers of all nations but our own. Our own writers largely 
follow Duhring in their description of the disease, and as 
soon as they vary from his description, it seems to me that, 
instead of simple impetigo, they describe the contagious 
form. I have never seen a case, and shall here follow 
Duhring. 

Impetigo simplex. Symptoms. The appearance of the 
disease may or may not be preceded by loss of appetite, con- 
stipation, or malaise. The eruption consists of one to a 
dozen or more pustules that are pustules from the begin- 



IMPETIGO. 287 

ning. They are split-pea to finger-nail in size; rounded; 
and raised above the surface of the skin. They have thick 
walls, a more or less marked areola, little surrounding infil- 
tration, and no central depression. Their color is yellowish 
or whitish. They manifest no disposition to rupture, are 
discrete and disseminated, and do not incline to coalesce. 
While they may occur anywhere they are seated by prefer- 
ence on the face, hands, feet, and lower extremities. Itch- 
ing and burning are absent, as a rule. The course of the 
disease is acute, its duration being several weeks. The 
pustules gradually undergo absorption and dry into a crust, 
or they may be ruptured by external injury. The crust 
when it falls leaves a reddish base without pigmentation or 
scar. It is not contagious, and occurs mostly in children. 
Such is the disease as described by Duhring. It will be 
seen by reading the next section that it bears a strong re- 
semblance to impetigo contagiosa. 

Impetigo Contagiosa. Synonyms : Porrigo contagiosa ; 
Impetigo parasitica. 

An acute, inflammatory, contagious disease, occurring 
especially on the face, hands, and exposed parts, and char- 
acterized by the appearance of vesico-pustules and bullae. 

Symptoms. By Tilbury Fox, who first described the 
disease, and others who followed him, its onset is said to be 
marked by slight febrile disturbances. These are very 
slight, and I have not satisfied myself as to their occurrence 
in the many cases that I have seen, except incidentally as 
part of some digestive disorder that may be present. The 
eruption consists of vesico-pustules that come out in crops. 
They are of various sizes, but average that of a split-pea. 
They are at first surrounded, in well-marked cases, with a 
red halo, which soon fades. They tend to increase slowly 
in size, and sometimes assume grotesque shapes. They are 
not fully distended, but flaccid, and not infrequently upon 
the hands will bear a strong resemblance to a burn of the 
second degree. If the covers of the vesicles or small bullae 
are not disturbed, their contents in a few days will dry up, 
and the vesico-pustule will change into a straw -yellow gran- 
ular crust, which is placed superficially upon the skin with 



288 DISEASES OF THE SKIN. 

its edge somewhat detached, and, it may be, turned up. In 
fact, it looks " stuck on." When the crust is removed or 
falls of itself, there is exposed an erythematous spot, which 
in a short time will disappear and leave no trace of its exist- 
ence. If the vesicles are torn by scratching, or if by any 
other means their covers are removed, we shall find very 
superficial losses of substance — a moist surface covered with 
a slight purulent secretion or crusted lesions. Even this 
disappears and leaves no trace, passing through the erythe- 
matous stage in its course to recovery. Such are the ap- 
pearances presented in the majority of cases. 

Besides this usual and typical form we meet with another 
and rarer variety, in which, instead of vesico-pustules, there 
are larger bullae. These may be several inches in their long 
diameter, are of irregular oval shape, not fully distended 
with fluid, and sometimes show a slight depression in their 
centers. Their contents are at first serous, but soon become 
sero-purulent. They seem to be longer preserved than the 
vesicles, but otherwise run the same course. At first they 
have a slight zone of redness about them, but this soon dis- 
appears. They either are formed by two or more vesico- 
pustules running together, or spring up of themselves. 
They may attain their full size at once, or increase slowly. 
Rarely do they exist alone ; generally the typical vesico- 
pustules will be found in their neighborhood or elsewhere 
on the body. It is the bullous form that is liable to be mis- 
taken for pemphigus. 

Impetigo contagiosa is located principally upon the face, 
most often on the chin, and on the hands ; it may also occur 
upon the scalp, legs, and trunk, especially in infants. Ac- 
cording to my experience, the bullous form is most often 
seen upon the trunk. The lesions of both varieties are dis- 
crete ; exceptionally two or more may run together. They 
are superficial, and rarely very numerous. The bullous 
lesions are generally widely separated from one another. 
The disease does not run any definite course, and may last 
weeks or months ; a slight amount of itching is sometimes 
present. 

Etiology. It is, as its name indicates, very contagious, 



IMPETIGO. 289 

and often occurs in epidemics. When one case is met with 
in dispensary service, several more may be expected in chil- 
dren of the same family or neighborhood. It is readily 
inoculable both on the subject of the disease and on others. 
Not infrequently we see a mother or other attendant of a 
child with the characteristic lesions of impetigo contagiosa 
upon the arms, derived from carrying the child suffering 
with the same disorder. What the contagious element may 
be is not yet determined with certainty, though various in- 
vestigators have described several parasites as the cause of 
the disease. We know that all pus is under certain circum- 
stances inoculable, and hence it has been maintained that 
there is no such disease, properly speaking, as contagious 
impetigo. But when we succeed in inoculating from an 
ordinary impetigo pustule, we produce an ordinary impetigo 
pustule, not the characteristic vesico-pustule of impetigo 
contagiosa. It has been stated by some authorities that the 
disease is due to an inflammation set up by lice on the head 
of the particular case or can be traced back to some other 
case of pediculosis. In some cases phtheiriasis capitis may 
be present, because both diseases occur with special fre- 
quence in children of the poor. In my own experience, in 
most cases no such relationship could be traced. A number 
of cases have been reported of the occurrence of contagious 
impetigo shortly after the fall of vaccine crusts, and thus 
has been suggested the possible connection between im- 
petigo and vaccinia. It is more frequent in the warm 
months than in the cold. Children furnish the vast ma- 
jority of the cases. 

Diagnosis. Impetigo contagiosa is diagnosticated by the 
presence of discrete, partially distended vesico-pustules, 
which are located upon the exposed parts — head, face, and 
hands — in most cases ; these are sometimes grouped, run 
an acute course, and dry up into straw-yellow " stuck -on " 
crusts. It is sometimes preceded by slight constitutional 
disturbances, and accompanied by a slight amount of itch- 
ing. It must be differentiated from simple impetigo, pus- 
tular eczema, varicella, scabies, pemphigus, and possibly 
ecthyma. 



290 DISEASES OF THE SKIN. 

The lesions of simple impetigo are pustules from the start, 
while those of impetigo contagiosa are first vesicles and then 
vesico-pustules. The pustules of impetigo are prominently 
raised, and run no definite course. The vesico-pustules of 
impetigo contagiosa are flattened, and run a rather definite 
course. The crusts of impetigo are generally greenish, while 
those of the contagious form are yellowish. Impetigo is not 
so readily inoculable as is impetigo contagiosa, and is much 
more widely disseminated, as a rule. Simple impetigo is a 
deeper process than the contagious form. 

Pustular eczema is itchy ; its pustules tend to break 
down quickly, run together, and form large patches, which 
soon become covered with a greenish or blackish crust. 
These phenomena are entirely foreign to impetigo conta- 
giosa. Eczema does not present vesico-pustules nor bullae, 
as a rule, and shows slight tendency to spontaneous recov- 
ery. Varicella is an an acute contagious disease, with con- 
stitutional symptoms in most cases. Its vesicles are smaller 
than those of impetigo contagiosa, and they run a definite 
course peculiar to themselves. They are widely distributed 
over the whole surface, usually appear first on the trunk, 
sometimes occur on the fauces, and not infrequently leave 
pitted scars. Contagious impetigo is in most cases limited 
to the exposed parts, it never occurs upon the fauces, and 
its lesions leave no trace. The crusts of varicella are small, 
while those of contagious impetigo are large 

The diagnosis from scabies offers little difficulty. In fact, 
the location of both diseases upon the back of the hands is 
their strongest point of resemblance When we bear in mind 
that scabies is very itchy, that it occurs usually as a copious 
eruption upon the hands, wrists, and forearms, about the 
umbilicus, or the nipples of females and the genitals of 
males ; that scratched papules and pustular lesions are more 
characteristic of it than vesicles, and that it presents the path- 
ognomonic furrows, we should not confound it with impetigo 
contagiosa, which has none of these symptoms. Further, 
impetigo will, in almost all cases, occur upon the face at the 
same time with the hands, and that location is very rarely 
attacked by the itch mite. 



IMPETIGO. 



291 



The diagnosis from pemphigus is by no means always 
easy. The occurrence of the bullous form of contagious 
impetigo is so rare that it is no wonder it is mistaken for 
pemphigus. Indeed, it is probable that not a few of the 
cases reported as acute pemphigus in children, which pos- 
sessed apparent contagious qualities, were instances of this 
bullous form of impetigo. The diagnosis between the two 
diseases can scarcely be made with certainty by the appear- 
ances of the bullae alone ; we must also take into considera- 
tion the general course of the disease. The differential 
diagnosis may be given as follows : 



Pemphigus. 



1. Occurs chiefly in adults. 

2. No source of contagion can be 

found. 

3. No particular sites of preference ; 

if anything, it is most frequent on 
the extremities. 

4. Chronic in its course ; marked by 

frequent relapses; may return 
from year to year. 

5. Bullae are fully distended with a 

clear fluid, so that their covers 
appear tense. They often spring 
up out of the sound skin with- 
out areola. 



Lesions often occur in great num- 
bers, so as to cover the whole 
body, and at times are prurigi- 
nous. 

Disease obstinate to treatment, 
and prognosis usually grave. 



Impetigo Contagiosa 
(Bullous form). 

1. Occurs chiefly in children. 

2. A source of contagion can usually 

be found. 

3. Met with most often upon the 

trunk , sometimes it may occur 
on the face, hands, or extremi- 
ties. 

4. Acute in its course, rarely lasting 

more than a few weeks. 

5. Bullae not fully distended, but 

flaccid, and contain sero-puru- 
lent fluid. They may have a 
well-marked red halo while 
slowly attaining their full size. 
Characteristic vesico-pustules are 
generally present elsewhere at 
the same time. 

6. Lesions, few in number, do not 

involve the whole body, and itch 
but little, if at all. 

7. Disease yields readily to treat- 

ment ; prognosis uniformly good. 



Ecthyma is probably only a form of impetigo contagiosa 
that occurs in broken-down subjects. It affects by prefer- 
ence the lower extremities, is seen most often in adults, and 
its lesions are deep pustules, which are highly inflammatory 
and painful. 

Treatment. The treatment of the usual form is to 
direct the affected parts to be scrubbed with warm water 
and soap, and covered with a 5 per cent, carbolized vaseline, 
or with oxide of zinc ointment with carbolic acid in the same 
strength, or with the ointment of the ammoniate of mercury 
diluted to half its strength. If there is a good deal of crust- 



292 DISEASES OF THE SKIN. 

ing, the crusts may readily be removed by soaking them 
with oil or hot water, after which the applications men- 
tioned may be made. In the bullous form it is well to prick 
the bullae at their most dependent part, and let the fluid 
escape, after which the lesions may be treated as just 
indicated. 

Prognosis. The prognosis of impetigo contagiosa is 
always good ; so readily is it cured that the patients seldom 
present themselves a third time at the dispensary. 

Impetigo Granulata. See Pediculosis. 

Impetigo Herpetiformis. This disease was first described 
by Hebra 1 in 1872. 

In this country it is exceedingly rare, only a few cases 
having been reported. We owe to Hebra and Kaposi nearly 
all we know about the disease, and it is from Kaposi 2 that 
the account here given is taken. 

The disease begins with an eruption of pustules in the 
genito-crural region, about the umbilicus, on the breasts, 
and in the axillae ; later upon various other locations. The 
pustules are crowded together, grouped, pin-head-size, with 
at first opaque, and later greenish-yellow contents. They 
dry into a dirty-brown crust, while immediately around 
them new pustules appear in double or threefold circles, 
by the drying of which the crust is enlarged. The disease 
spreads by the growth of the individual groups and by the 
coalescence of neighboring ones. Underneath the crusts 
the skin appears red and covered with new epidermis ; or 
deprived of epidermis, moist, infiltrated, and smooth ; or 
papillary, but never ulcerated. Within three or four months 
nearly the whole skin is involved, swollen, hot, covered with 
crusts, showing torn and excoriated places with here and 
there circles of pustules. The mucous membrane of the 
tongue may show circumscribed, gray patches. There is a 
continuous remittent fever, and each outbreak of pustules is 
marked by chills, high fever, and dry tongue. Nearly 

1 Wiener med Wochenschrift, 1872, No. 48. ^ 

2 Pathologie und Therapie der Hautkrankheiten. 



KELOID. 293 

all cases prove fatal. The disease has affected almost ex- 
clusively pregnant women, only one man having been re- 
ported with the malady. Delivery has not stopped the 
course of the disease. It is probably of septic origin. 

Diagnosis. The disease is stated by Kaposi to differ 
from dermatitis herpetiformis in being only pustular ; in 
its peculiar location and manner of spreading; in the ab- 
sence of itching ; in the severe constitutional symptoms ; 
and in its lethal ending. 

Treatment. No treatment has proved successful. We 
can only do our best to nourish the patient ; and by means 
of baths, dusting-powders, or alkaline lotions render her as 
comfortable as possible. 

Induratio Telae Cellulosae Neonatorum. See Sclerema 
neonatorum. 

Inflammatory Fungoid Neoplasm. See Mycosis fun- 
goides. 

Intertrigo. See Erythema intertrigo. 

Iodic Acne. See Dermatitis medicamentosa. 

Itch. See Scabies. 

Juckblattern. See Prurigo. 

Kahlheit. See Alopecia. 

Kelis. See Keloid. 

Keloid (Kel'oid). Synonyms : Kelis ; (Fr.) Cancer 
tubereux, Cheloide ; (Grer.) Knollenkrebs. 

A connective-tissue new growth in the skin, occurring 
most commonly upon the chest; characterized by hardness, 
by a pinkish color, and by sending off prolongations in all 
directions. (Fig. 34.) 

Symptoms. It is usual to divide keloids into two varie- 
ties, one of which is called the true or spontaneous keloid, 
and the other the false or secondary keloid the result of 
injuries. Of late the opinion is gaining ground that no 
such distinction can be made and that even the true keloid 
results from some slight injury. As most commonly met 



294 



DISEASES OF THE SKIN. 



with it consists in a single, firm, hard, pinkish, freely mov- 
ble, oval or elongated, elevated tumor upon the upper half 
of the sternum, from which claw-like processes are given off 
in all directions. While there may be but one tumor, the 
lesions may be multiple, there being either one large and 
several small ones upon the chest, or many scattered over 
the body. They begin as small, pinkish elevations and 



Fig. 34. 




Keloid. 1 



gradually enlarge until they attain a certain size, when they 
may remain stationary, or else slowly grow. They assume 
all sorts of shapes and sizes. Sometimes they have an 
even surface, sometimes they are nodular. They may be 
quite small, or they may be so large as to run nearly half- 
way across the chest. Then the appearance is as if the 

1 From G. H. Fox's Photographs of Skin Diseases. 



KELOID. 295 

skin were drawn up into the tumor. The epidermis is 
smooth over them, and the pink color is due to the dilated 
bloodvessels. Sometimes the color is white. Though they 
are rarely met with on the face in the white races, they are 
very common upon the face of negroes. They are often 
attended by a good deal of pain, or pruritus, or pricking 
sensations. 

Besides this form of keloid, that may or may not be spon- 
taneous, we have the evident scar keloid that occurs over 
the site of an injury to the skin. These have followed 
syphilides that have destroyed the skin, variola pustules, 
psoriasis, a blister, or acne. 1 They may be limited to the 
site of the previous lesion, or spread beyond it. This form 
of keloid is very often seen on the face of the male negro who 
shaves, the cheeks and chin being studded over with small, 
hard, white elevations. The hypertrophied scar resembles 
keloid, but never spreads beyond the limits of the injury, has 
no claw-like processes, is not so pinkish, nor so permanent. 

Etiology. We know scarcely anything as to the cause of 
keloid, and can only beg the question by saying that it is a 
predisposition on the part of the skin. It is probable that 
some minute injury precedes the tumor. The negro race is 
peculiarly prone to the disease. Sex is without influence, 
and it may occur at any age, though rare before puberty 
and in old age. Histologically the structure of the keloid is 
similar to that of the cicatrix — that is, it is a dense fibrous 
connective-tissue growth which has its seat in the true skin. 

Treatment. As a rule, it is safest to leave the growths 
alone. Cutting them out is often disappointing in its re- 
sults, as the growth is apt to return. Multiple scarifications 
followed by the application of acetic acid have been suc- 
cessful. Leloir and Vidal 2 recommend following multiple 
scarifications with a boric acid dressing. The next day mer- 
curial plaster is to be applied, and changed every morning 
and evening. Perseverance in this method, they say, may 
result in a cure. Compression by means of an elastic 

1 Purdon: Journ. Cutan. and Ven. Dis-, 1882-3, i. 203. 

2 Annal. Derm, et Syph., 1890, No. 3. 



296 DISEASES OF THE SKIN. 

bandage or by mercurial plaster sometimes reduces the 
prominence of the tumors. Hardaway has succeeded in 
removing one keloid and two hypertrophied scars by means 
of electrolysis, and Brocq has commended the method. A 
stout needle must be used and multiple punctures made in 
all directions, and in the tissues for a space beyond the 
tumor. Galvanism is said to reduce hypertrophied scars. 
Andeer 1 recommends resorcin and a bandage. Hypoder- 
matic injections of morphine, or the application of belladonna 
ointment, may be necessary to relieve pain. 

Peognosis. It is possible for keloids to undergo spon- 
taneous involution. This is especially the case in the scar 
keloid following syphilis. Usually this cannot be expected. 

Keloid of Addison. See Morphoea. 

Keloid of Alibert. See Keloid. 

Keratosis Circumscripta. See Ichthyosis. 

Keratosis Diffusa seu Epidermica. See Ichthyosis con- 
genita. 

Keratosis Follicularis (Ke 2 r-a 2 t-os'i 2 s fo 2 l-i k'uMai^is). 
This is a rare affection of the skin to which especial atten- 
tion has of late been given. It is probably the same as was 
described by Guibout by the name of acne sebacee cornee, 
and by Lesser as ichthyosis follicularis. The French have 
named it psorospermose folliculaire vegStante, but as this 
title was given it by Darier and Thibault in 1889, under 
the idea that it was due to psorosperms, a pathological basis 
that is not yet proven, and as Morrow 2 had already reported 
a case in 1886, with the title of keratosis follicularis, and 
White 3 another in 1889, under the same title, it seems to 
me best to retain their title. 

Symptoms. The disease affects nearly the whole cuta- 
neous surface, though both in Morrow's and White's cases 
the palms and soles were free. The eruption begins as pin- 
head-sized papules, which are firm and of the color of the 

1 Centralbl. f. nied. Wissenschaft, 1888, xxvi. 785. 

2 Journ. Cutan and Ven. Dis., 1886, iv. 257. 

3 Journ. Cutan. and Gen.-urin. Dis., 1889, vii. 201. 



KERATOSIS FOLLICULARIS. 297 

skin. As they increase in size they become hypersemic ; still 
growing, they become hemispherical or flattened, with 
smooth or polished, dense adherent coverings of nail-like 
consistence, and varying in color from dull red to purplish, 
dusky red, brown, and brownish black. Some of them are 
excoriated by scratching and bear hemorrhagic crusts. These 
lesions are discrete, and the skin about them normal. They 
are located in the hair follicles. In places the lesions run 
together and form elevated areas with uneven surfaces and 
covered by thick yellowish or brownish, flattened horny con- 
cretions ; or there may be brownish or blackish plates. The 
patches feel rough and somewhat greasy. Here and there 
will be found papillomatous excrescences ; or enormously 
dilated follicular openings filled by comedo-like, firm, slightly 
projecting concretions forming hemispherical elevations, 
which when expressed are found to be hard and perfectly 
dry, leaving the follicle mouth patulous. The nails are 
coarse, slightly thickened, and ragged at their free edges. 
Boeck 1 says that they are often the seat of a marked hyper- 
keratosis without a trace of the disease itself anywhere in 
their neighborhood. The hard palate in White's case showed 
some follicular elevations. Pruritus is marked in some cases. 
A fetid odor is given off from the patient. 

Upon the scalp the disease appears for a long time as a 
seborrhcea sicca, but later the same elevations about the 
hairs can be made out as are seen upon the general integu- 
ment. Upon the backs of the hands and fingers the erup- 
tion presents the appearance of simple papillary growths, 
little pale-white, slightly raised, confluent and adherent 
masses. Upon the palms and soles, instead of elevations, 
we find punctate depressions, and perhaps a hyperkeratosis. 
In the axillae on account of maceration by sweat the masses 
are not so hard and horny, and the scales can be rubbed off, 
when a moist, red, warty surface is exposed. 

The course of the disease is a progressive one by the 
springing up of new lesions. It develops symmetrically. 
It seems to have no damaging effect on the health. It 

1 Archiv f. Derm, und Syph., 1891, xxiii. 857. 



298 DISEASES OF THE SKIN. 

affects specially the scalp, axillae, inguinal region, abdomen 
below the umbilicus, backs of the hands and feet, and the 
wrists. 

Etiology. We know nothing positive about the etiology 
of this rare affection. White met with it in a father and 
daughter, and that would suggest the idea of heredity. 
The majority of the cases have been in males. 

The psorosperm of Darier is regarded by some as simply 
a changed epithelial cell, and of no importance as an etio- 
logical factor. Darier and many other competent observers 
hold that it is a true parasite, and the cause of the disease. 
The disease may begin at any age, cases having been re- 
ported as commencing in the first weeks of life, in the 
sixth, sixteenth, twenty-second, twenty- seventh, and thirty- 
sixth year, though most cases occur before the twenty-fifth 
year. 

Pathology. Bowen, who made a careful examination of 
White's first case, says that " the disease is a keratosis of the 
epithelial lining of the mouths of the follicles, which, by 
extension downward, gradually produces pouch-like depres- 
sions in the corium. The capacity for corneous metamor- 
phosis is so great that the central portion becomes a firm 
horn, which by production of horny matter from below is 
gradually pushed out above the surface of the skin. There 
was no proof that the sebaceous glands were affected by the 
horny change." Robinson found in Morrow's case that the 
changes occurred principally in the sebaceous glands. But 
the disease has not yet been sufficiently studied to warrant 
positive statements. The psorosperm is described as a sin- 
gle-celled organism, which is round, generally encysted, and 
contained in the epithelial cell. 

Diagnosis. The disease differs from pityriasis rubra 
pilaris in lacking the constant and early involvement of the 
palms and soles, and the extensive, diffused, scaly derma- 
titis of the face, neck, and other parts, and in having horny 
plugs. 

Treatment. The proper treatment is yet undeter- 
mined. It might be well to try the methods found useful in 
ichthyosis. 



KERATOSIS PILARIS. 299 

Keratosis Palmaris et Plantaris. This is a form of 
congenital callositas. It has also been called Keratoma 
palmare et plantare hereditarium, icthyosis palmaris et 
plantaris, tylosis palmse et plantse. It is characterized by 
the appearance upon the palms and soles of masses of 
thickened skin of leathery consistence and yellow or brown 
color. They come without apparent cause and usually 
show a symmetrical arrangement. The palms or the soles 
alone may be affected, but it is always both palms or both 
soles that are affected. There is sometimes a zone of red- 
ness about the thickened plates. Sometimes the whole palm 
or sole is covered, sometimes the horny masses occur in 
islands. The plates may be shed periodically only to reform. 
The surface of the plates may be smooth or uneven. Hyper- 
idrosis is frequently marked. The nails at times show 
hypertrophic changes. Pain may be complained of when 
the hands or feet are used. If the feet are affected, the 
pain may be so great as to prevent walking. 

Etiology. The disease is hereditary in many instances, 
and like ichthyosis tends to affect only one sex in a family. 
We do not know its cause, and we class it as a trophoneu- 
rosis. It sometimes has been noted to follow the prolonged 
ingestion of arsenic. 

Treatment. The plates may be removed by salicylic 
acid plaster ten to twenty per cent, strength. The same 
end is reached by poultices, the wearing of rubber sheeting, 
and the application of various plasters. A permanent cure 
can hardly be expected. 

Keratosis Pigmentosa. See Verruca senilis. 

Keratosis Pilaris (K. Pil-a'ri 2 s). Synonyms: Lichen 
pilaris ; Pityriasis pilaris : Ichthyosis seu hyperkeratosis 
follicularis ; Cacotrophia folliculorum ; (Fr.) Xerodermic 
pilaire, Ichthyose anserine des scrofuleux. 

Symptoms. As its name indicates, this is a disorder of 
cornification. It is characterized by a heaping up of the 
corneous cells about the mouths of the hair follicles in the 
form of small conical, whitish, or grayish elevations. Be- 
tween them the texture of the skin is normal : its color 



300 DISEASES OF THE SKIN. 

may be unchanged or rosy, or of a grayish or brownish 
shade. It occurs chiefly upon the extensor surfaces of the 
limbs, especially upon the upper arm and thigh, but may 
occur anywhere. The appearance of the affected part re- 
sembles cutis anserina, being dotted over with little pin- 
head to small-pea-sized papules, each one of which is either 
pierced by a hair or has a black dot at its summit indicat- 
ing the mouth of the hair follicle. The papules are often 
scaly. The hair is either normal, broken off, or only to be 
found by opening the papule, when it will be seen curled up 
inside of it. The skin feels dry and harsh. There may 
be slight pruritus. Pityriasis capitis may be present at the 
same time. As the disease is attended by but slight, if any, 
subjective symptoms it is often overlooked. It is a chronic 
affection in most cases. 

Brocq describes a Keratosis pilaris of the face beginning 
as minute scaly papules about the hairs, which crowd 
together to form patches and give a rosy or red tint to the 
skin. After a time the disease seems to destroy the follicle, 
and we find depressed scars arranged in rows or scat- 
tered about on the red patch. This bears some resemblance 
to lupus erythematosus, and is the ulerythema ophryogenes 
of Taenzer. Besnier describes a somewhat similar condition 
as occurring upon the extremities. 

Etiology. The disease is sometimes congenital and 
often forms a part of ichthyosis. It is most common in 
women, and those who do not bathe frequently, or in whom 
there is cutaneous inactivity. 

Diagnosis. It differs from cutis anserina in being a 
permanent condition ; from the miliary papular syphilide 
in being whitish, grayish, or blackish, and not dark -red or 
raw- ham color, and in being removable by soap and water. 
Lichen scrofulosorum occurs in strumous subjects and in 
well-marked circular or crescentic patches, which is foreign 
to keratosis. Papular eczema differs in being very itchy, 
and in having red inflammatory lesions. Ichthyosis is a 
general affection of congenital origin, and with peculiar 
markings of the skin, not being limited to the hair follicles. 

Treatment. The vigorous use of green soap and water 



KERION. 301 

in an alkaline bath, followed by oil or vaseline, will remove 
the evidences of the disease. Vapor or Russian baths may 
be used for the same purpose. Hyde prefers general cool 
baths containing one-quarter of a pound of common salt to 
each gallon of water, after taking which the skin is to be 
rubbed with a coarse towel or flesh-brush. As the affection 
is allied to ichthyosis it may be treated on the same plan, a 
new course of bathing being taken with each relapse. 

Keratosis Senilis. See Verruca senilis. 

Kerion (Ke'-ri 2 -o 2 n). Synonyms : Trichomykosis capil- 
litii ; Tinea kerion ; Kerion Celsi. 

Symptoms. This is a more or less chronic inflammation 
of the scalp or beard that most often is a form of ringworm, 
but may be produced quite independently of that disease. 
It is most commonly seen on the scalp. The affected part 
becomes red, oedematous, swollen, and boggy, and may 
assume a purplish color. Its surface is glazed, uneven, and 
studded with a number of yellowish suppurating points, or 
with foramina out of which oozes a sticky, viscid, gelati- 
nous, transparent fluid. Sometimes suppuration may occur 
attended with a sero-purulent discharge. The swelling is 
round or oval in shape, and varies in size ; it may be but 
one or two inches in diameter, or as large as a turkey's egg. 
The pustules form about the hair in the early stage ; later 
the hairs fall and the discharge takes place from the open- 
ings of the hair follicles. If the tumor is opened, a thick, 
viscid material escapes. If the disease occurs with ring- 
worm, the hair will be broken off. Permanent baldness 
may result if the inflammation is intense. There are more 
or less pain and tenderness, and at times itching and burn- 
ing. The posterior cervical glands may be enlarged. 

Etiology. The disease is comparatively rare. It occurs 
chiefly in children of poor constitution. It is most com- 
monly due to the trichophyton fungus passing deep down 
into the hair follicles, but may be caused by the application 
of irritants to the scalp, or follow eczema, favus, or sycosis 
of that part. 

Diagnosis. Kerion must be diagnosticated from abscess, 

14 



302 DISEASES OF THE SKIN. 

a papilloma, a gumma, and a sebaceous cyst. An abscess is 
not preceded by ringworm, has no history of an irritant 
applied to the scalp, and may arise without any antecedent 
disease of the scalp ; it is more painful ; it is often accom- 
panied by a sensation of throbbing, by chilliness, fever, and 
general malaise; when fully formed there is fluctuation, and 
when opened it gives exit to pus. These symptoms are not 
met with in kerion. A papilloma is non-inflammatory, firm 
to the touch, and is unaccompanied by a discharge. A 
gumma is usually accompanied by other signs of syphilis, 
and tends to break down and ulcerate. A sebaceous cyst is 
slow in its growth, the skin over it is normal, there is no 
discharge, and when opened it gives vent to a cheesy mass. 
A fatty tumor is a chronic, elastic, freely movable swelling, 
with normal skin over it. 

Treatment. In treating a case epilation should be per- 
formed in order to save the hair and give exit to the dis- 
charge. If some irritant application is the cause, that 
should be discontinued, and hot-water dressings, antiseptic 
solutions, or mild emollient applications employed. If the 
cause is ringworm, the remedies proper for that disease 
should at once be used. What they are will be found under 
Trichophytosis capitis. 

Kleienflechte. See Chromophytosis. 

Kohlenbeule. See Carbuncle. 

Kopskurv. See Favus. 

Knollenkrebs. See Keloid. 

Kratze. See Scabies. 

Kraurosis (Kra 4 -ro'-si 2 s) Vulvae is a name proposed by 
Breisky 1 for a form of atrophy of the skin of the external 
genitals of women. The disease has its seat in the vestibule, 
the labia minora with the frenulum and prseputium clitoridis, 
the inner surfaces of the labia majora up to the posterior 
commissure, and the contiguous skin of the perineum. It 
gives rise to the appearance of a defect in the development 

1 Zeitschrift f. Heilkunde, 1885. 



LENTIGO. 303 

of the normal folds of the vulva. At times^the labia minora 
and the prseputium clitoridis are apparently wanting. 1|The 
affected skin is white and dry, the epidermis is often thick- 
ened, and telangiectasic vessels are visible. Stenosis of the 
vulvar entrance may result and thus obstruction be offered 
both to coitus and parturition. The cause is obscure ; pos- 
sibly a long-continued blennorrhea, or a congenital defect, 
or a process analogous to leucoplakia buccalis. Treatment 
is of no effect. 1 

Krebs is the German for cancer. 

Kupferfinne. See Rosacea. 

Kupferrose. See Rosacea. 

Kupfriges G-esicht. See Rosacea. 

Lausesucht. See Pediculosis. 

Leberflecken. See Chloasma. 

Leichdorn. See Clavus. 

Leiomyoma Cutis. See Myoma. 

Lentigo (Le 2 nt-i / go). Synonyms : Ephelides ; (Ger.) 
Sommersprossen, Linsenflecke ; Freckles. 

Freckles are properly a species of chloasma. They occur 
as light to dark brown or even black macules, and are 
usually located upon exposed parts, especially the face and 
backs of the hands, but they may occur anywhere. In size 
they vary from a pin-head to a split-pea. They give rise to 
no subjective symptoms. They usually do not appear before 
the eighth year of life, but congenital cases have been 
reported. These should rather be classed among the pig- 
mentary nsevi. A division is sometimes made between those 
which are permanent and occur upon unexposed places and 
those which occur in summer to disappear in winter. To 
the former the name lentigo is given, and to the latter eph- 
elides. The distinction is not worth preserving. As old 
age is approached freckles no longer form, and the old ones 
are apt to disappear. 

1 Janovsky : Monatshefte f. prakt. Derniat., 1888, vii. 951. 



304 DISEASES OF THE SKIN. 

Etiology. The cause of freckles is probably an inborn 
peculiarity of the skin. It has been advanced as a theory 
of their production that they are due to the chemical action 
of the sun's rays upon the blood. Blondes are more prone 
to them than are brunettes. Many people never freckle. 
Symptomatically they occur as part of atrophoderma pig- 
mentosum. 

Pathology. Freckles are but circumscribed deposits of 
pigment. Cohn 1 has endeavored to show that lentigines 
differ from ephelides in being discrete, slightly elevated, and 
having their pigment in all the layers of the epidermis, as 
well as in the cutis, and in being associated with changes 
in the bloodvessels of the cutis ; while ephelides are crowded 
together, their pigment is only in the basal layer of the 
epidermis, and there are no changes in the bloodvessels. 

Treatment. The treatment of freckles is the same as 
that of chloasma. The only prevention is to protect the 
skin from the action of the sunlight. Hardaway recom- 
mends the following : 

R. Hydrarg. ammon., \„ . 4 

Bismuthi subnitrat. , / dJ ' 

Ungt. aq. rosse, ^j ; 30 M. 

He also speaks highly of electrolysis for the removal of 
very black freckles. There is hardly any use in endeavor- 
ing to cure freckles occurring from the action of the sun, 
as they depart of themselves. 

Lentigo Maligna. See Atrophoderma pigmentosum. 

Leontiasis. See Leprosy. 

Lepothrix. This is a condition of the hairs of the axillae 
and scrotum which presents itself as diffuse or nodular in- 
crustation of the hair, which is composed of a parasitic growth. 
The hairs are not diseased, but simply form a ground for the 
growth of the parasite. It is met with in those who sweat 
freely. Sometimes the masses are red. They may be 
removed by soap and water and prevented by the use of a 
mild antiparasitic lotion. 

1 Monatshefte f. prakt. Dermat., 1891, xii. 119. 



LEPRA. 



305 



Lepra (Le 2 p'ra 3 ). Synonyms : Elephantiasis Grsecorum ; 
Leontiasis ; Satyriasis ; Lepra Arabum ; (Fr.) La Lepre ; 
(Ger.) Der Aussatz ; (Norweg.) Spedalskhed ; Leprosy. 



Fig. 35. 




Tubercular and anaesthetic leprosy. 1 

A chronic, endemic, constitutional disease due to infection 
by a specific bacillus ; characterized by anaesthesia, erythe- 

1 From a photograph kindly loaned me by Dr. P. A. Morrow, of 
New York. 



306 DISEASES OF THE SKIN. 

matous patches, tubercles, ulcerations, atrophies, and de- 
formities according to the structures most affected; and 
ending in death. (Fig. 35.) 

Symptoms. It is usual to describe three forms of leprosy 
— the tubercular, the anaesthetic, and the mixed. This is 
convenient for clinical purposes, though not absolutely cor- 
rect, as even in the nearly pure tubercular form there is 
more or less anaesthesia. All forms exist in all endemic 
regions, but now one and now another form predominates. 
The tubercular form is the one most common in cold coun- 
tries, the anaesthetic in hot countries. Morrow, 1 however, 
found that in the Sandwich Islands the tubercular form con- 
stituted one-half of the cases, while the anaesthetic form 
formed but one-third of them. 

Tubercular leprosy. Sometimes this form appears sud- 
denly without prodromata, but usually for days, weeks, or 
months before the disease frankly declares itself the patient 
is out of health. He feels indefinitely ill, depressed, and 
listless ; he has dyspepsia and diarrhoea ; he is weak, chilly, 
and suffers from profuse sweating- There may be nose- 
bleed. Then a remittent fever of malarial type appears. 
This fever may occur without the other prodromata, and 
may recur with each new outbreak of tubercles. After a 
time an erythematous eruption appears upon the face, ears, 
the forearms and thighs. It consists of purplish or 
mahogany-red, slightly raised, hyperaesthetic, smooth, shiny 
patches, of one or several inches in diameter, usually of oval 
form. The eruption may fade entirely away, to appear 
again with a fresh outbreak of fever. After some three to 
six months of the exanthem the tubercles appear, either 
upon the sites of the previous lesions, or quite indepen- 
dently of them. They begin as pin-head-sized pink papules 
that enlarge to split-pea or even to hen's egg size, yellowish- 
brown tubercles. If a number of these run together, large 
infiltrated patches are formed of irregular shape and nodular 
surface. Then infiltrations may also arise by an increased 
deposit of leprous material in the macules, for the macules 

1 New York Med. Journ , 1889, 1. 85. 



LEPRA. 307 

themselves are formed of leprous material and are not sim- 
ply erythematous lesions. Sometimes the infiltrated patches 
that arise from the macules may assume ring-shapes, by 
clearing up in the centers. The tubercles are completely 
anaesthetic. They may come anywhere, but are most com- 
monly seen in the eyebrows, lobes of the ears, the face gen- 
erally, and upon the extremities. They are rare on the 
glans penis, palms, and soles. The scalp is said never to be 
affected. The mucous membranes of the mouth, nose, 
larynx, trachea, uterus, and vagina are also involved, as 
may be the conjunctivae. The tubercles may undergo 
spontaneous involution in one place, while fresh outbreaks 
of them occur in other places. Or they may soften and 
break down and form leprous ulcers, which are indolent, 
sharply defined, and glazed over with a mucous discharge 
of peculiar odor. These may attain enormous dimensions, 
becoming serpiginous and phagedenic. When these ulcers 
go deep, as they may do on the lower extremities especially, 
there may take place spontaneous amputation of the fingers, 
toes, or whole members. This is one form of mutilating 
leprosy, which is most frequently encountered in the anaes- 
thetic form of the disease. Or the tubercles may, on disap- 
pearing, leave atrophic spots. Their development and 
involution are always slow. The appearance of a well- 
developed case is striking. The face is deformed by the 
tubercles and assumes the " leonine" expression on account 
of the thickening of the eyebrows causing them to protrude 
so that the eyes are sunken and have a stern expression. 
The hair is wanting in the eyebrows. The immense lobes 
of the ears hang down. The lips protrude and are often 
everted. Tubercles stud the face. The forearms are 
enlarged and knobby. The hands are deformed. There is 
very commonly a discharge from the nose, a disagreeable 
odor from the mouth, and the sense of smell is lost. The 
eyesight is often lost, the voice is cracked and croaking. 
The lymphatic glands are often swollen. Happily, both in 
men and women sterility is the rule. There are commonly 
atrophy of the testicles and loss of sexual power in men. 
The disease is steadily progressive, and death occurs in 



308 DISEASES OF THE SKIN. 

eight years, on an average/ though the disease may last for 
many years. Crocker says 40 per cent, die of the disease 
itself, 40 per cent, die from renal or lung complications, and 
the rest from diarrhoea, anaemia, or general marasmus. 

Ancesthetic leprosy announces its onset not by febrile 
symptoms, but by shooting, lancinating pains in the chief 
nerve-trunks, as the ulnar, median, peroneal, and saphen- 
ous. There are also pain and tenderness in various places, 
and a state of general hyperesthesia. Itching is regarded 
by Morrow as being one of the most common and charac- 
teristic prodromata of this form of leprosy. There may 
also be symptoms of general malaise and digestive disturb- 
ances. A frequent early symptom is a vesicular or bullous 
eruption upon the fingers and toes, with at first serous, then 
purulent contents. These may burst and leave a white, 
shining, anaesthetic spot, or an ulceration that heals with an 
anaesthetic cicatrix. Numbness soon follows the hyperaes- 
thetic state. The patient cannot grasp things firmly, and 
the consequent unskilfulness of his actions may be the first 
thing to attract his attention. This shows muscular weak- 
ness as well as numbness. 

After some months of these prodromal symptoms an erup- 
tion of macules similar to those of the tubercular variety 
appears upon the extremities, face, and back. They are 
isolated, of oval shape, hardly raised above the surface, and 
of a pale yellow to reddish-brown color. These often enlarge 
peripherally and clear up or become atrophic in the center. 
Sometimes instead of being oval they will take the form of 
wide streaks or of gyrate figures. They are often hyperaes- 
thetic when newly formed, but always perfectly anaesthetic 
when they have become atrophic, and even before that in 
cases that have lasted some little time. The large nerve- 
trunks, as that of the ulnar, are at first hyperaesthetic, but 
later are anaesthetic and can be felt like a whip-cord, and 
rolled about under the finger without giving rise to pain. 
Anaesthetic areas will be found independently of the macules, 
and in old cases a rather general anaesthesia develops so that 
the patient burns himself without noticing it. The anaes- 
thetic areas are subject to change from time to time. Soli- 



LEPRA. 309 

tary bullae appear from time to time as well as urticaria-like 
lesions. Marked atrophy of the muscles of the hands and 
feet occurs, and paralysis of the extensor muscles of the 
second and third phalangeal joints. Wasted interossei mus- 
cles and permanent flexion of the last phalanges of the fin- 
gers give as characteristic an expression to the hand in this 
form of leprosy, as the tubercles do to the facial expression 
of the tubercular form. After some ten years or so, during 
which the greater part of the cutaneous surfaces may have 
become studded over with white, wrinkled, hairless, atrophic 
spots, the permanent stage is reached. During these years 
painless amputation of many of the joints may have occurred 
by a process of dry gangrene (Lepra mutilans). Erysipelas 
may occur. The nails and hair are shed. Sleeplessness 
may prove a distressing symptom. Loss of sexual power 
and sterility are manifest late in the disease. There is 
marked anaesthesia of the soft palate, uvula, and pharynx. 
This form lasts much longer than the tubercular form, fifteen 
years being an average duration. Sometimes a fair degree 
of health is preserved for a much greater length of time. 
In most all cases more or less hebetude of mind is marked, 
becoming more pronounced with the duration of the disease. 

The mixed form is a combination of the symptoms of the 
two former varieties, and perhaps is the one most commonly 
met with in this country. Indeed, it is the rule that all 
tubercular cases present certain symptoms of the anaesthetic 
form, and vice versa, the variety being named from the pre- 
vailing lesion. 

Etiology. Up to within a few years various agencies 
were regarded as causes of leprosy, such as residence by the 
seashore, eating of putrid fish, heredity ; but in the light 
of our present knowledge there is but one cause, and that is 
contagion. The limits of this book forbid full discussion of 
this interesting topic, but an incontrovertible argument for 
this view is found in the spread of the disease in the Sand- 
wich Islands, where, within a few years of its introduction, it 
has decimated the community. The contagiousness of the 
disease is a strong plea for the segregation of the lepers 
within our own country. 

14* 



310 DISEASES OF THE SKIN. 

Leprosy is seen in both sexes, though the male sex is 
more often affected. It is rare in children, and is never 
seen in infants ; a strong argument against heredity. Its 
incubation stage is very long, reaching over a period of 
years. It occurs in all countries and climates, but is en- 
demic in certain regions. It seems that a damp, cold climate 
or a hot, moist climate favors the disease. Sporadic cases 
have been reported, but careful investigation would doubt- 
less show that they have been exposed to contagion. Vac- 
cination has often been a carrier of contagion. 

Pathology. Constantly accumulating evidence points 
to the bacillus leproe as the disease-carrier. This has been 
found in the tubercles, the infiltrations, the lymphatic glands, 
nerves, spleen, liver, walls of the bloodvessels, hair follicles, 
and sebaceous glands. It was discovered by Hansen in 
1874, and since then has been studied by many pathologists. 
"This bacillus occurs as straight or very slightly curved 
rods, 5-0V0 °f an mca m l er }g tn ? an d may have knob-shaped 
expansions at their ends or in their length, due to the pres- 
ence of two to five spores.'' (Crocker.) Culture-experi- 
ments have for the most part failed, and inoculation-experi- 
ments have resulted negatively. 

Diagnosis. In a fully developed case little difficulty in 
diagnosis can arise. Sometimes lepra will need to be differ- 
entiated from erythema multiforme ; syphilis ; lupus ; inor- 
phoea ; and vitiligo. The presence of anaesthesia in any 
doubtful case will establish the diagnosis of leprosy. Besides 
this erythema runs a more acute course ; syphilis of the 
tubercular form presents redder tubercles, which ulcerate 
more readily, are grouped, and a history of syphilis is 
usually attainable ; the lupus tubercles are small, of apple- 
jelly color, soft, do not produce thickening of the eyebrows 
and nodular lobulation of the ears, and group themselves in 
patches in which cicatricial tissue will be found; morphoea has 
a lardaceous appearance with a violaceous border; vitiligo 
patches are more dead-white and sharply defined, while the 
skin is unaltered in texture and normal in sensation. 

Treatment. The best chance for recovery from leprosy 
is removal to a region where the disease is not endemic. 



LEPRA. 311 

This, with attention to hygiene, and a general tonic treat- 
ment, will do a great deal toward a cure. Of internal 
remedies, chaulmoogra oil holds the first rank, with an in- 
itial dose of three minims three times a day, and then grad- 
ually increased to as high a dose as the patient will stand. 
Nausea, vomiting, and diarrhoea show when this is reached. 
Fox 1 has cured one patient by giving nux vomica or strych- 
nine up to full constitutional effects, and then administering 
chaulmoogra oil continuously. Gurjun oil is also highly 
commended in an emulsion of one part of the oil and three 
parts of lime-water, of which the dose is half an ounce 
morning and night. 

Unna claims to have cured one case with sulpho-ichthyo- 
late of sodium, from six to forty-five grains a day, but others 
who have tried it have not had the same success. Salicy- 
late of soda, thirty grains every four hours till two drachms 
are taken ; salol in full doses ; thymol, forty-five to sixty 
grains a day ; carbolic acid up to fifteen grains a day, are 
advocated by Lutz, Besnier, and others. The general 
health of the patient should receive attention, and symp- 
toms treated as they arise. 

Externally the chaulmoogra or gurjun oil may be rubbed 
in. The ulcers are to be treated upon the usual surgical 
principles. Unna 2 recommends rubbing into all the lesions 
but those on the hands and face the following : 

R. Chrysarobin, \ .. 

Ichthyol, J 



Ac. salicyl., 2 

Ungt. simpl., 100 



M. 



On the face and hands he substitutes pyrogallol for the 
chrysarobin. To counteract the bad effects of the drugs he 
administers thirty drops of dilute hydrochloric acid during 
the day. For women and children he substitutes resorcin 
for the chrysarobin. To old nodes, after protecting the 
surrounding skin, he applies during five to seven days a 

1 Post-Graduate, 1885-6, i. 143. 

2 Journ. Cutan. and Gen.-urin. Dis., 1887, v. 381. 



312 DISEASES OF THE SKIN. 

plaster mull containing twenty to forty parts of salicylic 
acid and forty parts of creosote. The so-called Bhau Daji 
treatment 1 is said to have produced remarkable effects in 
from six to eight weeks after it was begun. It consists in 
the use of the oil of hydnocarpus inebrians, of which from 
"1,10 to gss is taken in the morning in boiled milk. The 
patient is also anointed with the oil. Two hours afterward 
the oil is washed off in a warm bath. He is anointed on 
going to bed. He is not allowed to eat pork, beef, or fish, 
nor to drink alcoholics, tea, or coffee. He is fed on milk, 
fruit, vegetables, butter, eggs, mutton, and fowls. Roake 2 
advocates excision of the tubercles, followed by the appli- 
cation of pure carbolic acid. The thermo- or electro- cautery 
may be used to the same end. Segregation is the only 
preventive measure. 

Prognosis. The prognosis is bad, as the disease steadily 
progresses to a fatal termination unless the patient .can be 
removed from the endemic region. If he can be removed, 
there is a chance of staying the disease. In some instances, 
the disease, even when the patient does not change his 
residence, pauses in its course for a long time ; but it will 
eventually again become active. 

Lepra Alphos. See Psoriasis. 

Lepra Arabum. See Elephantiasis. 

Lepre Vulgaire. See Psoriasis. 

Leprosy. See Lepra. 

Leucasmus. See Leucoderma, 

Leucoderma (Lu^ko-du'rm'a 3 ). Synonyms : Vitiligo ; 
Leucasmus ; Leucopathia ; Achroma ; Piebald skin. 

An acquired loss of pigment of the skin characterized by 
the formation of symmetrical white patches with convex 
borders surrounded by an area of hyper-pigmentation. 

Symptoms. This is an acquired anomaly of pigmenta- 
tion, the opposite to chloasma. It is akin to albinismus, 

1 Brit. Journ. Dermat., 1893, v. 203. 

2 Brit. Med. Journ., 1888, i. 1214 



LEUCODERMA. 



313 



only that the latter is a congenital condition. It consists 
in the disappearance of the pigment of the skin in circum- 



Fig. 36. 




Leucoderma. (After Hyde ) 



scribed round or oval patches so that white areas are formed 
(Fig. 36). At the same time there is an accumulation of 



314 DISEASES OF THE SKIN. 

pigment around the areas so that there is at once a process 
of apigmentation and hyper-pigmentation. The size of the 
patches varies greatly. They may be no larger than a ten- 
cent piece, or of immense size. The disease most commonly 
begins upon the neck, face, or backs of the hands, but may 
begin anywhere. It is chronic. It may progress so as 
eventually to involve nearly the whole body; or it may 
become stationary ; or, in rare cases, the skin may become 
pigmented again. It is a symmetrical disease in nearly all 
cases. The general health is unaffected, and there is no 
change in the sensibility of the patches. In some cases the 
white parts are unusually sensitive to exposure to the sun. 
When the scalp or hairy regions are affected the hair turns 
white. The disease is most evident in the summer on 
account of the increased pigmentation that normally occurs 
in the sound skin at this season. 

Etiology. The cause of the disease is obscure. All we 
can now say is that it is probably a disturbance of innerva- 
tion. It is uncommon for it to occur before the tenth year 
of life, though it may do so. Adults are most frequently 
affected. Both sexes are subject to it. It is more common 
in the warm than in the cold countries, and is particularly 
common in negroes. Exposure to the sun and cold seem to 
be excitants in some cases. It has followed typhoid fever, 
scarlatina, and malarial fever. Wood 1 says that when mulat- 
toes contract syphilis they become several shades lighter 
all over the body. Symptomatically it is seen with mor- 
phcea, Addison's disease, and alopecia areata. There is also 
a syphilitic leucoderma. I have had one case in a young 
man of eighteen years, who began to smoke tobacco when 
he was six years of age, and had continued to do so. He 
seemed to be in the best of health. 

Diagnosis. There is little difficulty in diagnosis, as 
there is no other disease in which the only symptom is a 
loss of pigment with surrounding pigmentation. In mor- 
phoea the patch may be raised, and the skin is changed in 
texture, and there is apt to be a lilac ring about it. In 

1 Journ. Cutan. and Yen. Dis., 1883, i. 274. 



LEUCOPATHIA UNGUIUM. 315 

chloasma the patch itself is dark with a convex border, while 
in leucoderma the border of the pigmentation is concave. 
The concave border of the pigmentation will also distin- 
guish the disease from chromophytosis, which too is scaly. 
The normal sensation of the patches distinguishes them from 
leprosy, in which the patches are anaesthetic. 

Treatment. Unfortunately there is hardly anything 
that can be done in the way of treatment. Galvanism or 
faradism may be tried, and nerve tonics given. We must 
content ourselves with making the patches less evident by 
removing the pigment from about them by the means given 
under chloasma. Or we can stain the patches so that they 
shall be less white, as by the use of walnut juice. Besnier 
and Doyon believe that they have cured cases in young sub- 
jects by the prolonged use of bromide of potassium inter- 
nally, and saline or bromo-iodide baths externally, with or 
without injections of pilocarpine. 

Leukaethiopes, a name applied to negro albinoes. 
Leucokeratose. See Leucoplakia. 
Leucopathia. See Leucoderma. 

Leucopathia Unguium. This affection consists in the 
appearance of white spots in the nail, which begin in 
the lunula, and gradually approach the free end of the nail 
as it grows forward. Sometimes these take the form of 
stripes or lines. Rarely the whole nail is affected. The 
nail-substance is otherwise unaltered. The spots are due 
to air-spaces in the nail-substance. Why these occur 
we do not know. Possibly there may be a process of fatty 
degeneration of the nerve-cells and subsequent absorption of 
the fat. (Taylor.) Or they may be caused by pressing back 
the nail-fold. They are common in the young, and coinci- 
dent with white spots in the teeth. (Hutchinson.) They 
very often are noticed after fevers or other lowered condi- 
tions of health. Nothing can be done for this deformity 
excepting caring for the general health of the patient and 
stopping any bad habit. 



316 DISEASES OF THE SKIN. 

Leucoplakia (Lu^ko-pla'kP-a 3 ). This is a rare affection 
of the mucous membrane of the tongue, lips, inside of the 
cheeks, and vulva, that has been described under the names 
of psoriasis buccalis, ichthyosis linguse, and tylosis linguae. 
It occurs in the form of ivory-white or bluish-white, glisten- 
ing, smooth, irregularly shaped patches upon the mucous 
membranes that may be a little elevated. They may give 
rise to no discomfort, or they may interfere with chewing 
and speaking. They may be fissured. There is sometimes 
salivation. They are caused by smoking, or occur in syphilis, 
psoriasis, lithsemia, stomachic or intestinal catarrh, diabetes, 
and disturbed nervous influences. Sometimes they arise 
without assignable cause. 

They are obstinate to treatment. It is very essential 
that tobacco be given up if the patient has been in the habit 
of using it. It is also necessary to address our remedies 
to the cure or relief of any lithaemic or digestive disorder ; 
and to have' the teeth put and kept in good order. An anti- 
syphilitic treatment may be tried, but is of doubtful value. 
Sometimes they may be removed by the daily application of 
pure lactic acid ; or ^ per cent, solution of bichloride of 
mercury ; or 10 to 30 per cent, solution of salicylic acid ; or 
1 per cent, of chromic acid ; or 2 to 10 per cent, of bichro- 
mate of potash ; or by galvano or actual cautery. 

The prognosis as to cure is not good. They not infre- 
quently take on a cancerous change. 

Lichen (Li r ke 2 n). This term was formerly applied to all 
papular diseases, and a host of lichens were described. Of 
these, only lichen ruber, lichen planus, and lichen scrofulo- 
sorum have survived. 

Lichen Circinatus. See Seborrhcea. 

Lichen Moniliformis. See Lichen planus. 

Lichen Pilaris. See Keratosis pilaris. 

Lichen Plants. A chronic disease of the skin charac- 
terized by the eruption of smooth, waxy, angular, umbili- 
cated, red papules, that tend to form scaly, lilac-colored, 



LICHEN PLANUS. 317 

elevated and infiltrated patches specially upon the flexor 
surfaces of the wrists and the inside of the knees. 

While the testimony from skilled observers is overwhelm- 
ing that lichen planus papules may occur with lichen ruber, 
and while some cases of lichen ruber have developed after 
and together with lichen planus, still we see so many cases of 
the latter occurring by itself that it merits a special descrip- 
tion. In this country and in England lichen planus is far 
more frequent than is lichen acuminatus, and is regarded as 
a separate disease. While the latter occurred but 27 times 
in 123,746 cases, the former occurred 154 times in the 
same number of cases, according to the statistics of the 
American Dermatological Association. 

Symptoms. The disease begins as an eruption of small, 
purplish- or crimson-red, angular, flat, slightly raised papules, 
varying in size from -^ to ^ of an inch in diameter. Their 
surface is smooth and shiny, u waxy-looking," and they have 
a small depression in the center. The papules may remain 
discrete, and be disseminated over a larger or smaller area ; 
or they may arrange themselves in rows, or aggregate them- 
selves into patches, the single papules disappearing. The 
single papules are not scaly, the patches are slightly so. 
The patches may be small, and if so there is apt to be a well- 
marked depression in their center, and their shape is round 
or oval. The larger patches have no" definite shape nor de- 
pression, but are well defined and elevated. Characteristic 
single papules will be found scattered about in the neighbor- 
hood of the patches. The color of the patches is character- 
istic, and may be defined as lilac. It is an important aid in 
diagnosis. Both the papules and patches on disappearing 
leave behind pigmented, slightly atrophic spots, which, after 
a time, fade away. It is still a moot-point as to whether the 
individual papule enlarges peripherally or not. Like those 
of psoriasis, the papules of lichen planus may appear upon 
scratched surfaces. 

The disease is most often met with upon the anterior sur- 
face of the wrists and forearms, and upon the inside of the 
knees, the former being the favorite location. But it may 
occur anywhere, other favorite locations being the flanks, 



3 J 8 DISEASES OF THE SKIN. 

lower part of the abdomen, and the calves, and it may in- 
volve a large part of the body, though it rarely becomes 
general. The mucous membranes of the lips and mouth are 
affected but rarely, and the disease then appears as white 
spots difficult if not impossible of diagnosis without the oc- 

FiG. 37. 













Lichen ruber moniliformis. (After Taylor.) 

currence of the* typical eruption on the integument. As a 
rule, there is more or less symmetry shown in the disposition 
of the efflorescences ; and pruritus, which sometimes is 
marked. The general health is often unaffected, but, on 
the other hand, many of the subjects of the disease are not 



LICHEN PLANUS. 31 9 

in perfect condition when the disease begins, and not a few 
others become greatly broken down on account of the loss of 
sleep and continual discomfort caused by the pruritus. The 
course of the disease is chronic, and new outbreaks are liable 
to occur. True relapses usually do not occur when the dis- 
ease is once cured. 

Kaposi 1 has described a unique form of this disease 
under the name of lichen ruber moniliformis, in which the 
typical lesions became transformed into keloidal nodes 
arranged in lines (Fig. 37). The nodes were in some 
places as large as cherries with their bases confluent and 
their upper parts separated by furrows. The cases of this 
sort that I have seen in this country occurred in what were 
rather lichen ruber acuminatus or pityriasis rubra pilaris. 
Unna 2 describes what he names lichen obtusus, a form of 
papule midway between the acuminate and the plane. They 
are large and waxy, discrete papules, often bluish-white, not 
scaly, and but slightly itchy. A lichen verrucosus and a 
lichen hypertrophicus have also been described. Pemphi- 
goid eruptions occasionally occur as part of the disease. 
Crocker says that there is an infantile form of the disease 
in which the papules come out acutely in groups, acuminate 
at first, but soon becoming flat, angular, and red, changing 
to purple. It is itchy, and tends to rapid recovery in a few 
weeks under soothing applications. 

Etiology. We know no more about the causes of lichen 
planus than we do about those of lichen ruber. A neurotic 
element is marked in many of the cases, and cases have 
been reported in which the papules were distributed along 
the course of a nerve. 3 Nervous exhaustion, rheumatic 
sweating, and checking perspiration are given as causes. 
Its subjects are mostly adults. It is more frequent in men 
than in women. 

Pathology. " In the plane form the process appears to 
be inflammatory, beginning usually round a sweat duct in 

1 Vierteljahr. f. Dermat. u Syph., 1886, xiii. 571. 

2 St. Petersburg, med. Wochenschrift, 1884, i. 447. 

3 Mackenzie: Brit. Med. Journ., 1884, ii. 1077. 



320 DISEASES OF THE SKIK 

the upper part of the corium, with subsequent thickening 
of the rete and enlargement of the papillae by down growth 
of the inter-papillary processes." (Crocker.) The fact that 
the mucous membranes are affected is brought forward as an 
objection to the view that the process begins in the sweat 
duct. Robinson thinks that the process begins as an inflam- 
mation of the papillae and upper part of the corium. The 
form of the papule is determined by the shape of the so- 
called "skin fields." 

Diagnosis. An eruption of flat, shiny, angular, umbili- 
cated papules of a lilac color situated on the anterior sur- 
faces of the wrists can be nothing but lichen planus. These 
same characteristics are diagnostic anywhere on the body, 
and sufficient to distinguish the disease from eczema and 
psoriaris. Moreover, eczema will show a tendency to 
moisture, or the papules will undergo change ; and psoriasis 
will be almost sure to have characteristic patches upon the 
elbows and knees, covered with more abundant white and oft- 
times thick scales. Syphilis sometimes bears a strong resem- 
blance to lichen planus, but itching is less marked, its eruption 
is more polymorphous, and its color is more that of raw ham. 

Treatment. In the treatment of lichen planus, arsenic, 
nerve tonics, and attention to the general health as well as 
to the hygiene both of the body and mind, are our most 
reliable agents. Alkaline diuretics sometimes do well, as 
the acetate of potash. Locally stimulants such as tar, 
pyrogallol, and chrysarobin will prove serviceable. Unna's 
ointment, as given under lichen ruber acuminatus, is proba- 
bly our most reliable application. In acute cases alkaline 
lotions will allay irritation. Thymol and naphthol may be 
tried as in lichen acuminatus. In chronic cases Hardaway 
recommends: 



Saponis olivse prep., 


§iv; 


100 


Olei rusci, \ . . 
Glycerinse, f 


&j; 


25 


01. rosmarini, 


Sjss ; 


4 


Alcoholis, ad 


Iviij; 


200 



M. 

well rubbed in with a piece of flannel. The patches are 
sometimes favorably affected by mercurial plaster. Some 



LICHEN RUBER. 321 

cases in which the skin is very irritable are best treated by 
means of prolonged simple or medicated emollient baths. 
Jacquet and other French dermatologists report excellent 
results from the use of spinal douches of water of varying 
temperature and force. 

Prognosis. The prognosis is generally favorable, though 
the disease is often very obstinate. 

Lichen Polymorphe Chronique. See Prurigo. 

Lichen Ruber. Though it is many years since Hebra 
first described this disease, dermatologists are still unde- 
cided as to many of its essential features, such as whether 
lichen planus is but a form of lichen ruber acuminatus, or 
a disease sui generis ; and as to whether the separate 
lesion of lichen ruber increases peripherally or not. In this 
country the acuminate form of the disease is very rare, only 
fifty-two cases having been reported to the American Der- 
matological Association for sixteen years out of a total of 
204,866. While in Europe lichen planus is considered as 
only a form of lichen ruber, in this country and in England 
it is regarded by probably the majority of our dermatologists 
as a separate disease, and will be described as such in this 
book. On account of the diversity in the descriptions of 
lichen ruber, the one here given is taken from Hebra and 
Kaposi {Lehrbuch der Mautkranklieiten, 1872). 

Lichen ruber or lichen ruber acuminatus is a chronic pro- 
gressive disease of the skin marked by an eruption of small, 
red, conical papules tipped with a scale. These tend to 
run together and form lines or diffused red, scaly, infiltrated 
patches. 

Symptoms. The disease begins as a discrete eruption of 
milletseed-sized, slightly scaly papules, that cause but little 
itching, and therefore are accompanied by but few excoria- 
tions. The papules may be bright or brownish red, conical, 
hard, covered with an adherent, dry, white scale, and im- 
parting, when they are present in a sufficient number, a 
rough feeling to the touch. Or they may be pale red, waxy, 
smooth, rounded, and with a small angular depression in 
their center. The first outbreak may be scattered about 



322 DISEASES OF THE SKIN. 

the whole trunk and extremities, though somewhat more 
abundant on the flexor surfaces of the latter. Or it may 
be limited for a long time to a single region, such as the 
leg or genitals. After a time the eruption becomes general 
by the appearance of new papules either at the periphery 
of the first patch, or between the original papules, or irreg- 
ularly over all. The single papules never increase in size 
during their whole course. After a time the papules crowd 
together, and melt into each other and form continuous, 
red, infiltrated patches of various sizes and shapes, whose 
surfaces are like shagreen leather or covered with scales. 

This is the most common course. Sometimes, however, 
the new papules appear in manifold circular rows about the 
older ones. The older ones sink in, disappear, and leave a 
darkly pigmented depression. The thus formed patches are 
usually on the extremities. 

In a fully developed case the skin is everywhere reddened, 
scaly, and thickened, and the movements of the joints are 
greatly interfered with so that they are held in a semi- 
flexed position. The thickening of the skin is specially 
marked on the palms, soles, fingers, and toes, and here rhag- 
ades are prone to form. The nails are thickened, uneven, 
brittle, broken, opaque, yellowish-brown ; or they are only 
represented by thin horny plates. The coarse hair of the 
head, axillae, and pubes is unaffected. Kaposi, in the third 
edition of his book, says that a defluvium capillorum takes 
place. 

The subjective symptoms are itching and a gradual pro- 
gressive interference with nutrition. At first the patient 
may feel quite well, but when the whole body is affected he 
falls into a general marasmus, and at last dies from the effects 
of the disease. 

So far Hebra. Subsequent observers have reported the 
occurrence of a bullous eruption in the course of the dis- 
ease. 

Etiology. The cause of the disease is obscure. It 
affects all ages and conditions, but is most frequent in the 
male sex — about two-thirds of the cases. By many the dis- 
ease is considered to be a neurosis. 



LICHEN RUBER. 323 

Diagnosis. It is needful to diagnosticate the disease from 
psoriasis, eczema, pityriasis rubra, pityriasis rubra pilaris, 
and lichen planus. From 'psoriasis it differs, when in the 
early stages, in that its papules do not enlarge into the large, 
characteristic psoriatic papules and patches ; in the later 
stages there is less scaling than in psoriasis universalis, and 
more thickening of the skin ; and the palms and soles are 
far more profoundly diseased. From eczema it differs in 
that its papules neither undergo involution nor change into 
vesicles Moreover, it does not itch so much, and there is 
never any moisture. From pityriasis rubra it differs in the 
greater thickening of the skin, and in its scaling, which is 
not in the form of thin plates or furfuraceous desquamation. 
From pityriasis rubra pilaris it differs in being less scaly, in 
affecting the flexor surfaces by preference, in the darker color 
of the eruption from the first, in being more itchy, and in 
the profound constitutional disturbance. Nevertheless the 
opinion is gaining ground that the two diseases are identical. 
From lichen planus it differs in that it does not have its 
favorite locations upon the flexor surface of the wrists and 
inside of the knees, in having conical and not flattened 
papules, in not forming lilac-colored angular patches, and in 
a more frequent general involvement of the skin. 

Treatment. Arsenic, by the mouth or hypodermati- 
cally is the drug upon which most reliance is placed for the 
cure of this disease. The drug must be pushed up to its 
limit of toleration and given continuously for a long time, 
and for some weeks after the disappearance of the eruption. 
The hypodermic method is very painful. The external 
treatment is by means of tar, if not too irritating, or we 
may simply address ourselves to the relief of the itching by 
means of carbolic acid, one or two drachms to the pint of 
olive oil or pound of vaseline. Crocker speaks well of 
thymol or naphthol, 10 gr. to 5ij to the ounce of vaseline. 
Unna's 1 treatment has proved serviceable in many hands. 
He keeps the patient in bed between woollen blankets, and 
has him rubbed every morning and night with the following : 

1 Monatshefte f. prakt. Dermat., 1892, i. 5. 



324 DISEASES 01 THE SKIN. 

R • Ungt. zinc. oxid. benzoat., J; iv ; 500 

Ac. carbolici, Biv; 20 

Hydrarg. bichlor., gr. ij-iv; 0.5-1 M. 

For the ointment of oxide of zinc, diachylon ointment may 
be substituted ; or a mixture of oil, lime-water, and white 
bole may be used instead. Where the corneous layer is 
very thick, two drachms and a half of chalk may be substi- 
tuted for the bole. 

Prognosis. The course of the disease is essentially 
chronic. Even when a cure is effected, relapses are lia- 
ble to occur. Hebra at first said that all cases were fatal, 
but the use of arsenic and increased experience in the treat- 
ment of the disease have greatly modified his gloomy prog- 
nosis. 

Lichen Scrofulosorum (L. Skro 2 f-u 2 l-os-or'u 3 m) or Scrofu- 
losus. A disease of the skin occurring in strumous sub- 
jects, consisting in an eruption of small pale papules that tend 
to group in round or half-moon-shaped figures upon the ab- 
domen, sides of the chest, and flanks. 

Symptoms. It occurs in the form of pin-point to pin-head- 
sized, grouped, conical papules, which may be of the color 
of the skin, or pale red, or fawn- colored. These papules 
occur around the hair follicles and form small round groups, 
or circles, or segments of circles, upon the abdomen, sides of 
the chest, flanks, and neck in adults ; and upon the extremi- 
ties in children. They are somewhat scaly, but give rise to 
no inconvenience, so that they are often overlooked. In some 
cases the papules are so numerous that the groups lose their 
distinctive shape, and large surfaces are covered, giving the 
skin a dirty-brown color. Many disseminated and discrete 
papules are scattered over the body outside of the patches. 
Acne pustules may form ; and a brown pigmentation of the 
face has been observed in some cases. The papules finally 
undergo absorption, desquamate, and leave transitory yel- 
lowish pigmentation. The disease runs a chronic, slow 
course. Eczema may complicate matters. Keratosis pilaris 
is frequently well marked upon the limbs. 

Etiology. The great majority of the subjects of this dis- 
ease present evidences of scrofula. A few are robust. Some 



LINSENFLECKEN. 325 

are phthisical, especially the children. The disease is most 
common in childhood, and is exceedingly uncommon after 
the twenty-fifth year of life. 

Diagnosis. The disease must be diagnosticated from 
papular eczema, the papular syphilide, lichen ruber, a punc- 
tate psoriasis, and keratosis pilaris. Eczema differs from it 
in greater itching, in the brightness and rapid development 
of the papules, and in its tendency to vesiculation or moist- 
ure. The papular syphilide is of darker red color, much 
larger, and more polymorphous ; the patient's age is usually 
greater, and the history and course of the eruption will soon 
decide the diagnosis. Lichen ruber has darker papules, 
which do not group in circles and segments of circles ; they 
itch, and tend to involve the whole surface. The patients 
are more often adults, and there is a profound constitutional 
disturbance. Psoriasis itches, is abundantly scaly, and its 
papules soon enlarge and form characteristic patches. 
Keratosis pilaris affects the extensor surfaces of the limbs 
by preference, each papule is plainly about a hair, and the 
papules do not group. A curled-up hair will often be found 
in the center of the papule. 

Treatment. The persistent use of cod-liver oil both 
internally and externally will cure the disease. The syrup 
of the iodide of iron or the iodide of starch may be given 
with the oil. Good hygiene and food are valuable adjuncts. 
For the cod-liver oil, which is disagreeable for external use, 
other oils, such as cocoa-butter, may be used ; or vaseline 
with or without oil of cade, Crocker recommends the addi- 
tion of liq. plumb, subacetatis, tt^xv, or thymol, 5 grains 
to the ounce of vaseline. 

Lichen Simplex. See Papular eczema. 
Lichen Syphiliticus. See Papular syphilide. 
Lichen Tropicus. See Miliaria. 
Lichen Urticatus. See Urticaria. 
Lineae Albicantes. See Atrophoderma. 
Linsenflecken. See Lentigo. 

15 



326 DISEASES OF THE SKIN. 

Liodermia Essentialis. See Atrophoderma pigmentosum. 

Lipoma is a fatty tumor. 

Liver Spot. See Chloasma. 

Lombardian Leprosy. See Pellagra. 

Lousiness. See Pediculosis. 

Lues. See Syphilis. 

Lupoid Acne. See Acne frontalis, and Lupus miliaris. 

Lupus Erythematosus. (Lu'pus Er 2 -i 2 -the 2 m-a 2 t-osVs). 
Synonyms : Seborrhoea congestiva ; Lupus superficial ; 
Lupus sebaceus ; Lupus erythematodes ; Scrofulide erythe- 
mateuse, or Erytheme centrifuge (Fr.) ; Dermatitis glandu- 
laris erythematosa (Morison) ; Ulerythema (Unna). 

This is a chronic disease of the skin, occurring in vari- 
ously sized, slightly elevated, scaly, red patches which show 
a strong tendency to the production of atrophic scars. 

Symptoms. There are two varieties commonly described, 
namely, the circumscribed or discoid, and the diffuse, or dis- 
seminated, or aggregated. To these some of the English 
writers add a third, the telangiectic. 

The circumscribed or discoid form is the one most often 
met with. It occurs generally on the face, specially upon 
the sides of the nose and the cheeks, the scalp, and the ears ; 
more rarely upon the hands and feet ; and still more rarely 
on other parts of the body. It begins by the appearance of 
several isolated or grouped red spots slightly elevated, of 
pin-head to split-pea size, with a thin adherent scale upon 
them. Some of these spots may be depressed in the center. 
When the scale is removed there will be found upon its 
under side a delicate projection formed by a plug of sebace- 
ous matter that dipped down into the mouth of the sebace- 
ous gland. The mouth of the gland will be found patulous. 
These spots increase in size by peripheral extension to form 
disc-shaped figures of varying size ; neighboring ones will 
coalesce, and thus patches will be formed, also covered with 
the fine grayish or white adherent scales. Now when the 
scale is raised a number of the characteristic prolongations 



LUPUS ERYTHEMATOSUS. 327 

will be found on its lower side. The margins of the patches 
are slightly raised, but the middle parts undergo involution, 
are lower than the margins, and after a time are apt to 
assume a cicatricial appearance, the skin being atrophied. 

The scar-tissue thus formed is thin, delicate, and white, 
never puckered or deforming. The color of the patches is 
red, but of a peculiar hue that is characteristic, and perhaps 
can be best defined as violaceous. There is never any 
moisture connected with the disease. Burning or itching 
may or may not be present. The patches are of indefinite 
duration — months or years. At times they disappear of 
themselves, and do not leave scars, but the rule is that scars 
are left. The extent of the disease varies greatly, as well as 
the shape of the patches. The greater part of the face may 
be involved, or there may be only a single patch. Usually 
the eruption is symmetrical. A characteristic location for 
the disease is upon the back and sides of the nose and the 
contiguous parts of the cheeks, forming what has been fanci- 
fully called a butterfly, the ridge of the nose representing 
the back of the animal, and the cheeks its wings. Some- 
times gyrate figures are formed. The mucous membranes 
and the vermilion border of the lips may be affected, pre- 
senting patches with punctate excoriations of red color, or 
spotted with grayish masses of exudation and superficial 
cicatrices. Occurring upon the scalp it leads to permanent 
loss of hair, and the same may be said of it as it occurs on 
other hairy parts. The disease may become stationary after 
a time. Relapses are liable to occur. The general health 
is unaffected. 

The diffuse or disseminate form is a more acute process, 
and exceedingly rare in this country. In it the patches may 
appear suddenly, or slowly develop. They are from pin- 
head to finger-nail size, slightly elevated, reddish-brown, 
hyperaemic and hard ; they pale under pressure, and are 
attended with heat and burning. In this stage they re- 
semble an urticaria, or the papular stage of eczema. There 
may be twenty to a hundred or more of them, crowded 
together upon the face and scattered over the body. Many of 
them may disappear in a few days without leaving any trace, 



328 DISEASES OF THE SKIN. 

while others will remain and become characteristic patches 
of lupus erythematosus with depressed cicatrices. The indi- 
vidual lesions do not increase in size, and the patches are 
formed by aggregations of single lesions. The eruption 
may be accompanied by a high degree of inflammation, ex- 
udation, and crusting, or even by bullae. There may be 
deep, painful subcutaneous tumors in the joints and glands 
at first, over which characteristic patches will form. In 
some acute cases the development of the patches is accom- 
panied by fever, osteocopic pains, and nocturnal headache. 
Or there may be a persistent inflammation of the face, ery- 
sipelas perstans, which may lead through a typhoid state to 
death. There may also be swelling of the parotid glands, 
and of various lymphatic glands. In some cases the disease 
bears a close resemblance to chilblain. 

The telangiectic form occurs, according to Crocker, as a 
persistent circumscribed redness, which close inspection shows 
to be due to dilated vessels, and is commonly located symme- 
trically upon both cheeks. Upon pinching up the skin it 
will be found to be markedly thickened. Some few come- 
dones may be present. There is no desquamation. 

Etiology. About two-thirds of the cases occur in 
women. It seldom occurs before puberty, though Kaposi 
has seen a case in a child of three years. Beyond these 
facts we know but little of its etiology. The French regard 
it as a scrofulous affection. Nothing suggesting its relation 
to a tuberculous process has ever been found in the skin. 
It is true that some few cases have reacted to tuberculin 
injections, but that is no proof of its tubercular origin. On 
account of not a few patients having other symptoms of a 
general tuberculosis, or giving a history of tuberculosis in 
other members of their family, Besnier regards lupus ery- 
thematosus as allied to lupus vulgaris, and as a species of 
tuberculosis of the skin. Crocker suggests a feeble circula- 
tion, and prolonged exposure to great cold or heat as possi- 
ble causes. It would also seem that those who are subjects 
of seborrhoea are predisposed to the disaase. 

Pathology. In spite of much careful study it is still 
undetermined whether the disease is inflammatory or not. 



LUPUS ERYTHEMATOSUS. 329 

In the majority of cases the disease begins about the seba- 
ceous glands and hair follicles. It may also begin in the 
sweat glands, or in any part of the skin ; or in the deeper 
layers of the skin around the vessels of the sweat or seba- 
ceous glands. The cicatricial scarring is the result of 
atrophic processes. 

Diagnosis. The disease must be differentiated from lupus 
vulgaris, eczema, rosacea, psoriasis, and syphilis. A typi- 
cal case occurring upon the face in the form of red patches, 
with fine cicatrices in the center, and covered with a deli- 
cate white or grayish adherent scale, from the underside of 
which are a number of projections, offers no difficulty in 
diagnosis. Lupus vulgaris differs from lupus erythema- 
tosus in occurring before puberty, in showing no disposition 
to symmetry, in the presence of apple-jelly tubercles, in 
being a deeper-seated disease, and in leading to far more 
disfiguring cicatrices. Eczema never leaves scars, is prone 
to exudation, itches, its scales do not show prolongations 
from the underside, and its patches undergo more rapid and 
varied changes. Psoriasis will be pretty sure to show 
characteristic patches covered with thick scales, and never 
causes scarring or leads to permanent loss of hair. Rosacea 
is largely composed of dilated bloodvessels, occupies the 
middle third of the face, often presents superficial pustules, 
does not leave scars, and is subject to frequent exacerba- 
tions. In syphilis a history of other lesions will be obtain- 
able, there will be more evident infiltration, and the course 
of the lesions will be more rapid. The disseminate form of 
the disease would be very difficult of diagnosis at first, but 
as soon as characteristic patches form the difficulty would 
be removed. 

When lupus erythematosus occurs upon the scalp it 
causes a bald spot that may be mistaken for alopecia areata, 
but differs from it in its irregular shape, in the signs of 
inflammation in it, and in the cicatricial condition of the 
scalp it leaves. A microscopical examination of the hairs 
from about a patch will decide as between lupus erythema- 
tosus and/ayus or ringworm. 

Treatment. Little beyond the care of the general con- 



330 DISEASES OF THE SKIN. 

dition of the patient upon general principles can be done 
for lupus erythematosus in the way of internal medication. 
McCall Anderson advocates the use of iodide of starch, 
made by triturating twenty -four grains of iodine with a little 
water, and gradually adding one ounce of starch, rubbing 
them well together until a deep-blue color of the mass is 
struck. Of this a heaped teaspoonful, increased gradually, 
may be given three times a day in water or gruel. Iodide 
of potassium is also commended, as are phosphorus and 
salicylate of soda. 

Our main reliance is upon external treatment. Some- 
times in the early stages alkaline washes, such as lotions of 
zinc or lead, may be used. Or one composed of 

ft. Zinci sulphat., \ -- . 



Potassii sulphurat. 

Alcohol, % iij ; 10 

Aquae rosse, ad ^fiv; 100 



M. 



as in acne and rosacea. Green soap or prepared olive soap, 
or its tincture, may be used in more chronic cases. This 
is often serviceable for the disease as it attacks the eyelids. 
The affected parts are to be well rubbed with it, using a piece 
of flannel. The process is to be repeated every few days. 
If the reaction is too great, a little oil or a glycerin lotion 
may be applied. Crocker advocates the addition of one or 
two drachms of the oil of cade to the ounce of the tincture 
of the soap. Carbolic acid, pure, applied to the patches, 
often acts admirably. It turns them white at first. The 
application is to be repeated as soon as the crust falls. 
Fowler's solution applied externally is sometimes effica- 
cious, but painful. Pyrogallic acid, 10 per cent, in oint- 
ment, sometimes does well : as also chloracetic acid ; oil of 
cade ; solution of naphthol, 1 per cent. ; resorcin 3 to 10 per 
cent, strength in solution or ointment ; tincture of iodine 
or iodide of glycerin ; caustic potash, one part to six or 
twelve of water. Hydronaphthol plaster and resorcin plas- 
ters of 10 to 20 per cent, strength and mercurial plaster 
are often excellent when persisted in. Sulphur or ichthyol 
in ointment or paste does well in some cases. Thilanin some- 



L UP US MILIABIS. 331 

times does well. All cases should be carefully watched that 
the reaction from our remedies does not go too far. If these 
superficial caustics do not cure, resort may be had to linear 
scarifications, making a series of cross-hatchings, taking care 
not to go very deep. The bleeding is to be checked by 
pressure and the application of carbolic acid, two drachms 
to the ounce. Limited surfaces must be taken at a time. 
Electrolysis by means of multiple punctures will sometimes 
give brilliant results. Sometimes running the needle across 
the patch, making a number of parallel insertions, will have 
a good effect. Erasion with the curette, galvano or Paque- 
lin cautery, and strong escharotics, such as the acid nitrate 
of mercury, may have to be used in very obstinate cases, but 
not till all other means are exhausted, as they are apt leave 
deep scars. 

Prognosis. The prognosis should be guarded, as the 
disease is a most obstinate one, and prone to relapses. A 
cure may, however, be effected by patient perseverance. It 
is wise always to tell our patients that scars are liable to be 
left, not only by the treatment employed, but by the disease 
itself. An accidental attack of facial erysipelas cured one 
case under my observation. The discoid form has little effect 
upon the health of the patient, but the disseminated variety 
not infrequently ends fatally. 

Lupus Exedens. See Lupus vulgaris. This term is 
sometimes applied by surgeons to epithelioma. 

Lupus Exfoliativus. See Lupus vulgaris. 

Lupus Exulcerans. See Lupus vulgaris. 

Lupus Hypertrophicus. See Lupus vulgaris. 

Lupus Miliaris or Lupoid or Adenoid Acne is a rare 
disease of the skin that occurs upon the cheeks in the form 
of discrete, pin-head-sized, deep-red, slightly raised papules, 
which do not tend to suppurate. Sometimes the papules 
will disappear, leaving a pit behind. The papules must be 
treated by very much the same remedies as are useful in 
lupus, such as by salicylic acid plaster, or acid nitrate of 
mercury. 



332 DISEASES OF 1HE SKIN. 

Lupus Sclereux. See Tuberculosis verrucosa cutis. 
Lupus Sebaceus. See Lupus erythematosus. 
Lupus Superficialis. See Lupus erythematosus. 
Lupus Tuberculosus. See Lupus vulgaris. 
Lupus Verrucosus. See Lupus vulgaris. 
Lupus Vorax. See Lupus vulgaris. 

Lupus Vulgaris (L. Vu 3 l-ga-ri 2 s). Synonyms : Besides 
those given above, which merely describe certain stages or 
forms of the disease, and are quite unnecessary to be re- 
membered, we have : Noli me tangere ; Herpes esthio- 
menos ; (Fr.) Dartre rongeante, Scrofulide tuberculeuse, 
Esthiomene ; (Ger.) Fressende Flechte. 

This is a chronic neoplastic disease of the skin due to its 
invasion by the tubercle bacillus, and characterized by one 
or more brownish-red papules, tubercles, or infiltrated 
patches, that tend either to absorption or ulceration, and 
always leave scars. 

Symptoms. Lupus vulgaris usually begins in childhood 
and upon the face ; the cheek and nose being the parts most 
usually affected. The initial lesion is a dark-red or brown 
pin-point to pin-head-size papule, which may be on a level 
with the skin, depressed below, or raised above it. There 
may be but a single lesion, but more usually there are a 
few of them either grouped or scattered. After a time 
slightly scaly patches will form by the coalescence of the 
lesions which have enlarged, into brownish-red, semi-trans- 
lucent, smooth, shiny tubercles, or by the development of 
new lesions between the old ones. The size of the patches 
varies greatly, but they are always elevated above the sur- 
face of the skin, of a dark-red color, and studded with the 
little brownish-red papules, or so-called tubercles. The 
appearance of these tubercles has been likened by Hutchin- 
son to that of apple-jelly. There may be but one patch, or 
the whole face may be more or less covered with a number 
of them. Symmetry is not a feature of the disease, often 
only one side of the face being affected. Sometimes two or 



LUPUS VULGARIS. 333 

more patches will coalesce at their borders, their centers will 
fade out, or rather become atrophic, and we will have a 
gyrate patch creeping over the skin with a well-marked, 
elevated red border. The center of all the patches is lower 
than the border, and eventually is atrophic. The course of 
the disease is slow and chronic, and the fate of the patches 
varies greatly. For months or years they may remain 
absolutely quiet, and then show signs of activity by new 
lesions appearing about the edges of the patches or in the 
scar-tissue. The patches may entirely disappear, leaving a 
fine, smooth cicatrix; this is rare without treatment. Or 
they may break down and form ulcers, which are irregu- 
larly rounded in shape, shallow, with easily bleeding floors, 
and a moderate amount of purulent secretion that dries into 
a crust. This is the so-called lupus exulcerans, and is not 
very frequent in this country according to my experience. 
Sometimes upon this ulcerated surface papillary or warty 
growths will spring up, the so-called lupus papillomatosus 
or verrucosus. Sometimes the infiltration of the patch is 
unusually great, and then we have lupus hypertrophicus. 
Most commonly we have a non-ulcerated, exceedingly 
chronic infiltrated patch with areas of cicatricial tissue scat- 
tered through it. When the disease attacks the end of 
the nose it will cause it to shrink up and convert it into cica- 
tricial tissue. When the ear is diseased it also shrinks up 
so as to be half the size it was originally. These changes 
are due either to ulceration or to the gradual absorption 
of the lupus tubercles that they all undergo. 

While the face is the site of predilection of lupus, it may 
also occur upon any part of the skin of the body, as well 
as upon the mucous membranes. In this latter situation it 
is most often secondary to the disease elsewhere, still it is 
often primary. Thus Bender 1 found that 30 t 3 q- per cent, of 
all his lupus cases began in the nasal mucous membrane. 
Pontoppidan also found the origin of the disease to be the 
nasal mucous membrane in many cases. In the nose it 
frequently leads to perforation of the septum and sometimes 

1 Vierteljahr. f. Derm, und Syph., 1888, xv. 891. 
15* 



334 DISEASES OF THE SKIN. 

great deformity of the nose, but it does not attack the 
bones. All other mucous membranes may be attacked ; 
the rectum and vagina being least often affected. Upon 
mucous membranes we do not see the same tubercles as 
on the skin, but papillary excrescences which form patches. 
They may be absorbed or ulcerate. The conjunctivae 
may be involved primarily or secondarily. Epithelial can- 
cer has developed in very rare instances upon the lupoid 
tissue itself, more commonly upon the scar-tissue left by the 
lupus. Whenever it develops as a sequela of lupus its 
course is more rapid and its prognosis far more grave than 
is usually the case. Erysipelas is a not infrequent compli- 
cation of lupus, and is sometimes curative in its action. 
Lupus of the extremities is often followed by permanent 
deformities and disabilities, and sometimes by tubercular 
lymphangitis. Implication of the lymphatic glands is 
exceptional in lupus, and then only in advanced cases. 

Etiology. Lupus has long been regarded as a manifes- 
tation of scrofula. It is now pretty well demonstrated that 
it is a tubercular disease. It should be placed under the 
division of tuberculosis cutis, but usage makes it advisable 
to consider it by itself. Many patients with lupus are 
plainly strumous; many, 55 T 9 ^ per cent, of Sach's 1 cases, are 
either tuberculous themselves or have a decided history of 
the occurrence of phthisis in their family. The phthisical 
history is far less pronounced in this country than it is in 
Europe. It is no uncommon thing for several members of 
the same family to have lupus. It is probable that we 
could find a close connection between lupus and infection 
with the tuberculous virus in all cases, were it practicable 
to do so. Another evidence of its tubercular origin is found 
in the nearly uniform reaction of lupus to tuberculin. It 
is much more frequent in females than in males, about 62 
per cent, being in females according to Block's and Sach's 
statistics. It begins in more than half the cases before the 
fifteenth year. It may begin as early as the second year. 
It is almost always a disease of youth. 

1 Vierteljahr. f. Derm, und Syph., 1888, xiii. 241. 



LUPUS VULGARIS. 335 

Pathology. The pathology of lupus has been studied 
by many competent investigators. As their results do not 
altogether agree, this is no place to discuss them. " It is a 
neoplasm of the granuloma class, and consists of a small- 
cell infiltration which begins in the deep part of the corium, 
and from thence gradually invades all the other skin struc- 
tures/' says Crocker. The tubercle bacillus is found in the 
tissues, though but sparsely. Inoculations have not always 
been successful, but in a goodly number of cases the inocu- 
lations have been followed by general tuberculosis, so as to 
warrant our belief in the tubercular nature of the disease. 
It has been suggested that as the bacilli are present in but 
a small number, the irritation of the tissues is due to the 
leucoma'ines produced by them. 

Diagnosis. Lupus is most commonly confounded with a 
tubercular or gummous syphilide. It may have to be dif- 
ferentiated sometimes from a scrofuloderm originating in a 
caseous gland, from an epithelioma, lupus erythematosus, and 
possibly lepra. From syphilis it is diagnosticated by the 
presence of the characteristic apple-jelly tubercles; by its 
slow course ; by its history ; by the absence of all other 
signs of syphilis ; by its little tendency to ulceration ; by 
the superficial character of its ulcers and their slight crust- 
ing ; and by its sparing the bones. If there is still any 
doubt, appeal may be made to the effect of treatment by 
means of the iodide of potassium and mercury, which will 
have no effect upon the lupus. As the scrofuloderm is an- 
other manifestation of the tubercular diathesis and amenable 
to the same treatment as that of lupus, its differentiation is 
not so important. It, however, will begin about a caseous 
and broken-down lymphatic gland, will probably have sinu- 
ses, and no characteristic tubercles. An epithelioma begins 
usually after the thirty- fifth year ; has no tubercles ; and 
forms a deep ulcer with raised, hard, waxy edges crossed 
with dilated bloodvessels. The diagnosis from lupus ery- 
thematosus is given in the preceding section. Leprosy 
presents large tubercles which are anaesthetic, and this at 
once decides in its favor. 

Treatment. As lupus is a tubercular disease, and some- 



336 



DISEASES OF THE SKIN. 



times is followed by tuberculosis of the lungs, care must be 
given to the general health of the patient, and he must be 
placed in the best possible hygienic surroundings. His diet 
should be nutritious, and cod-liver oil, iodine, and iron 
should be given. But external treatment is of the greatest 
importance, and the disease must be gotten rid of root and 
branch. If a single diseased cell remains, the disease is 
sure to return. To effect its destruction surgical procedures 
had best be resorted to. The whole patch or patches may 
be scraped out with the dermal curette, and this followed by 
a 25 or 30 per cent, pyrogallol ointment for a week or ten 
days, and that in turn by the mercurial plaster for another 
equal term. The pyrogallol will cause free suppuration and 
destroy the cells left behind by the curette. A second or 
third course may be necessary. Piffard prefers to touch the 



Fig. 38. 




Scarifying-knife 



base left after curetting with the galvano-cautery at a red 
heat. The wound is then to be packed with absorbent 
cotton. After about ten to fourteen days the crust and 
cotton will fall off and leave a soft, smooth, pliable cicatrix. 
Multiple scarifications have proved of great use. They may 
be made with many-bladed instruments constructed for the 
purpose, or with a scalpel, or a knife shaped like a butcher's 
cleaver (Fig. 38). They must go deep enough to penetrate 
all the softened tissue, but not to wound the sound parts. 
The resistance offered by the healthy tissues will be suffi- 
cient guide for this. The scarifications should be so made 
as to divide the tissues into little squares, thus: 




They may be repeated in five or six days, and need no 
after-treatment. This is Vidal's method. The individual 



LUPUS VULGARIS. 337 

tubercles may be bored out with Morris's double-screw in- 
strument, or with dental burrs and hooks as proposed by Dr. 
George H. Fox. Pure carbolic acid may be introduced 
into the little holes so left to insure the further destruction 
of the disease. The galvano or Paquelin cautery may be 
employed to destroy the disease. This will require the 
administration of an anaesthetic, while the former procedures 
do not require it, or at most anything more than local 
anaesthesia by means of cocaine. Multiple punctures by 
means of the galvano- or thermo-cautery at sombre red heat 
at 1 mm. distance for small patches and linear scarifications 
with cautery knife for large ones, followed by emplast. vigo, 
and repeated once a week, is Besnier's method. Electrol- 
ysis in multiple punctures or by passing the needle through 
the patch or by means of a flat metallic button, is a useful 
mode of treatment. The current must measure 3 to 5 milli- 
amperes, and it must be continued for five minutes, when 
the button is used. Auspitz recommends puncturing the 
patches in many places with a steel point dipped in carbolic 
acid. Small patches may be excised. 

These surgical procedures have largely superseded the 
use of caustics, though the latter are valuable and may be 
used when the patient fears an operation. Arsenic may be 
employed in the form of a paste such as Hebra's modifica- 
tion of Cosme's Paste : 

]£. Ac. arsenios., gr. x; 2 

Hydrarg. sulphureti rubri, ^j ; 12 50 

Ungt. aq. rosse, ^ j ; 100 M. 

which is to be spread on lint or linen, applied evenly, and 
bound down firmly. It is to be left on for twenty-four 
hours, then removed and reapplied till ulceration is set up. 
It is painful. Vienna paste, of equal parts of caustic potash 
and unslacked lime ; or a chloride of zinc paste may be 
used, such as 1 part of zinc to 3 parts of starch. Both are 
painful. Many think highly of boring into the patch with 
the solid nitrate of silver stick. Salicylic acid, 10 to 20 
per cent., in plaster or plaster muslin changed once or twice 
a day is good. It is well to combine creosote with the 



338 DISEASES OF THE SKIN. 

salicylic acid two parts to one, to allay the pain caused by the 
acid. The local application of bichloride of mercury in 
solution (gr. j to Sj) to ulcerated forms, and in ointment to 
non-ulcerated forms, is commended by White and others. 

Unna 1 recommends painting with pure carbolic acid for 
from two to four days. He has also had good results with 
a salve muslin containing 1 per cent, of bichloride of mer- 
cury, 20 per cent, of carbolic acid, and 36 per cent, of 
oxide of zinc. He 2 has also recommended the following pro- 
cedure : Little sticks of hard wood are sharpened and then 
soaked for several days in a solution of 



&. Hydrarg. bichlor., 


1 


Ac. salicylic, 


10 


Etheris sulph , 


25 


01 olivae, 


100 



M. 

These sticks are forced into each tubercle, cut off close to 
the skin, and covered with gutta percha or carbolized mer- 
curial plaster. After two days the plaster is removed, 
leaving a surface covered with a thin layer of pus. The 
holes made by the sticks are enlarged and the sticks lie 
loose in them. The sticks are removed, the surface asep- 
tically cleansed, the holes filled with a powder of 



R. Hydrarg. bichlor., 





Magnes. carbonat, 


10 


Ac. salicylic, 


5 


Cocain. muriat, 






M. 

which is blown on with a powder-blower and worked in by 
the fingers or with a wooden spatula. It is again covered 
with the plaster for twenty-four hours, when the procedure 
is repeated for another day. The subsequent treatment is 
by pyrogallic acid. 

Tuberculin has not proved as valuable as it promised. 
Only very few cases have been reported as cured. The 
inconvenience, depression, and sometimes fatal results from 
the remedy render it an unfit one for use. 

1 Monatshefte f. prakt. Derm., 1891, xii. 341. 

2 Ibid., 1895, xxi. 281. 



LYMPHANGIOMA. 339 

Prognosis. The prognosis should always be guarded. 
Relapses after any plan are too often seen. A scar must 
result both from the disease and its treatment. The possi- 
bility of the development of a general tuberculosis must 
also be borne in mind, although most patients preserve 
throughout the course of the disease a robust state of 
health. 

Lymphangiectasis (Li 2 mf-a 2 n-ji 2 -e 2 k r ta 3 -si 2 s). Varices of 
the dermal lymphatics may be superficial or deep ; and affect 
the trunk, the meshes, or the lacuna?, though most com- 
monly all parts of the vessels are diseased. When they are 
superficial they form ampullary swellings at the surface of 
the skin which may be isolated or agglomerated. In size 
they vary from the size of a millet-seed to that of a pea, or 
larger. In color they vary with that of the skin. They 
break more or less easily and discharge the lymphatic fluid. 
If deep, they can be more readily felt than seen, or form 
upon the surface of the skin isolated or associated raised 
cords which run a more or less tortuous course. After a 
time these also break and discharge lymph. 

Hallopeau and Goupii 1 describe under this title a disease 
that they believe to be of tubercular origin, and that appears 
about a bony prominence of the extremities as a diffuse 
tumefaction, or a cushion-like elevation resembling varicose 
vein tumors. They eventually open and discharge pure 
lymph, or lymph mixed with pus. Fresh tumors arise in 
the course of the lymphatics in an ascending series ; also 
gummy nodes. The affected limb is swollen, indurated, 
and of more or less sombre red. The prognosis is grave, 
and the proper treatment undetermined. 

Lymphangioma (Li 2 mf-a 2 n-ji 2 -o'ma 3 ), also called Lymph- 
angiectasis, Lymphangiectodes, Lupus Lymphaticus, and 
Lymphorrhagica Pachydermia, is an exceedingly rare dis- 
ease. It consists, according to Crocker, in a number of 
minute, deep-seated vesicles, closely crowded together in 
irregularly outlined groups of from one-third to one-quarter 

1 Ann. Derm, et Syph., 1890, i. 957. 



340 



DISEASES OF THE SKIN. 



of an inch in size. These groups are arranged irregularly 
with healthy skin between them, or a few scattered vesicles 
in the otherwise healthy skin. They are usually confined 
to a single small area. The vesicles are deep-seated with 
thick walls, some of them almost warty-looking. They are 
pin-point to hemp-seed size, colorless or straw-colored, or 
pinkish, and contain a clear fluid. Some have vascular 
striae or tufts over them, others red clots, others contain 
extravasated blood. 



Fig. 39. 




Lymphangioma. (Epstein.) 1 



They run a chronic, non-inflammatory course, spreading 
slowly at the periphery, and tending to relapse if removed. 
Most of the few cases have occurred in males and began in 
early childhood. 

The disease is of lymphatic origin, and the main feature 
is dilated lymphatic vessels. 

The treatment consists in destruction by caustics, excision, 
or electrolysis, but relapses are liable to occur. 

1 By permission from Journ. Cut. and Gen.-urin. Dis., 1892, x. 214. 



MEASLES. 341 

A number of other rare affections of the lymphatics have 
been named lymphangioma. The present state of our 
knowledge in regard to them is by no means exact. One 
variety is named by Kaposi 

Lymphangioma Tuberosum Multiplex. This is a still 
more rare disease than lymphangioma, and consisted, in 
Kaposi's case, in the appearance all over the trunk and 
neck of hundreds of lentil-sized, rounded, brownish-red, 
smooth, glistening, disseminated, flat, or elevated tuber- 
cles. They were firm and elastic, slightly painful, and 
upon some of them were dilated bloodvessels. One or two 
other cases of the same kind have been reported by others. 
By some this disease is regarded as a species of benign 
cystic epithelioma. 

Lymphoderma Perniciosa. See Mycosis fungoides. 

Lymphosarcoma. See Sarcoma. 

Maculae et Striae Atrophicae. See Atrophoderma stria- 
tum et maculacum. 

Maculae Caeruleae. See Pediculosis corporis. 

Madura Foot. See Fungous Foot of India. 

Madesis or Maderosis is an obsolete term for thinning of 
the hair. 

Mai de la Rosa. See Pellagra. 

Mai Rosso. See Pellagra. 

Maladie des Vagabonds. See Pediculosis. 

Malignant Papillary Dermatitis. See Paget's Disease. 

Malignant Pustule. See Pustula maligna. 

Malingering. See Feigned eruptions. 

Malleus. See Equinia. 

Mamillaris Maligna. See Paget's Disease. 

Mask. See Chloasma. 

Measles. See Morbilli. 



342 DISEASES OF THE SKIN. 

Medicinal Eruptions. See Dermatitis medicamentosa. 

Melanoderma. See Chloasma. 

Melasma. See Chloasma. 

Melanosarcoma. See Sarcoma. 

Melanosis Lenticularis Progressiva. See Atrophoderma 
pigmentosum. 

Melitagra. See Pustular eczema. 

Mentagra. See Sycosis. 

Microsporon furfur is the parasite of chromophytosis, 
which see. 

Miliaria (Mi 2 l-i 2 -a'ri 2 - a 3 ). Synonyms: Sudamina; Lichen 
tropicus ; (Ger.) Frieselauschlag ; Prickly heat. 

This is a disease of the sweat glands due to excessive 
sweating, which may or may not be inflammatory, and is 
characterized by an eruption of discrete papules, vesicles, 
or pustules. Several varieties are described, but it is enough 
to distinguish two forms, namely, sudamina and lichen 
tropicus. 

Symptoms. Sudamina, also called miliaria crystallina, 
is the form that is met with during the course of febrile dis- 
eases, and occurs as an eruption of an immense number of 
small, closely crowded, but discrete, bright, pearly vesicles 
entirely without inflammation or subjective symptoms. They 
are most abundant on the trunk, especially upon its anterior 
plane, but may occur anywhere. After lasting a few days 
they are absorbed and disappear by drying up, possibly 
with some scaling, or they may rupture and dry up. 

Lichen tropicus is very commonly seen in this country 
during warm weather. It may consist in an eruption of 
pin-point, bright-red papules (miliaria papulosa) ; or of very 
small vesicles upon an inflamed skin (miliaria rubra) ; or the 
eruption may be a composite one of papules interspersed 
with vesicles and pustules. Whichever form it may assume 
the lesions are present in great number, and closely crowded 
together, though not aggregated. It may involve the whole 



MILIARIA. 343 

surface, but is most common on covered parts, and specially 
upon the trunk. The eruption is apt to become better or 
worse according to the changes in the temperature of the 
atmosphere. The disease may last in this way throughout 
the warm weather. It is no uncommon thing for furuncles 
to form, and even cutaneous abscesses. Itching, prickling, 
and burning are always annoying accompaniments. If the 
skin is much scratched, eczema may complicate the disease. 
The old nurse's " red gum," the strophulus of older writers, 
is a miliaria. Kaposi regards the disease as an eczema. 

Etiology. The cause of sudamina is retained sweat, 
owing, probably, to epithelium clogging up the sweat pores 
when sweating is stopped on account of the fever. Lichen 
tropicus is due to congestion about the sweat pores and irri- 
tation of the skin when profuse sweating is induced by too 
warm clothing and hot weather. It is also suggested that 
checking a profuse sweat may cause it. It is seen most 
commonly in babies and fat people. It is noticeable in this 
city (New York) that the children who live near the river- 
front and are a good deal in the salt water escape the dis- 
ease, while it is very common in the rest of the tenement- 
house population. 

Diagnosis. Sudamina differs from vesicular eczema by 
its sudden occurrence during a febrile process ; by being 
non-inflammatory ; by its vesicles not breaking down ; and 
by not itching. Lichen tropicus differs from eczema by the 
minuteness of its papules ; by its sudden appearance ; by 
not forming patches which are moist ; by having a high 
atmospheric temperature as an evident etiological factor, 
and by the tingling rather than the itching of the eruption. 

Treatment. Sudamina needs no treatment, as with the 
subsidence of the fever it gets well of itself. Lichen tropi- 
cus requires attention to the diet, cutting off the meat in 
children, and lessening its amount in adults. Cooling 
drinks and the administration of gentle saline laxatives 
are also advisable. Locally, bathing in salt water or alka- 
line lotions, and subsequent powdering of the skin, conjoined 
with wearing light clothing, and not using too warm bed- 
covers, will relieve and ofttimes cure the trouble. 



344 DISEASES OF THE SKIN. 

Miliary Fever, or the sweating sickness, is an epidemic 
disease accompanied by profuse sweating and miliaria. The 
epidemics have occurred most often in France. 

Milium (Mi 2 l-i 2 -u 3 m). Synonyms : Grutum ; Strophulus 
albidus ; Acne albida ; Tuberculum sebaceum. 

Symptoms. These are small pin-head to split-pea sized, 
firm, whitish, or yellowish, slightly elevated papules that 
occur usually upon the face. They are spherical in shape, 
and slowly increase in size up to a certain point, when they 
remain stationary. When incised and pressed upon later- 
ally a small white, round, oval, or lobulated mass emerges. 
They give rise to no subjective sensation. While their most 
common site is the face below the eyes, they may occur any- 
where on the face ; and also upon the border of the lips, the 
penis, and scrotum. In this latter situation they are more 
decidedly yellow in color, flat, and often attain the size of a 
small bean. Along the corona glandis they are sometimes 
very thickly strewn. On the genitals of women their most 
frequent site is the labia minora. There may be but one or 
two, or a score of them. Occurring in the eyelids they are 
called chalazion. When they undergo calcareous degenera- 
tion (an infrequent occurrence), they form cutaneous calculi. 
Comedones are often present at the same time with milia. 
Any part of the body may be affected. 

Etiology. Milia occur chiefly in infants and young 
adults, and sometimes follow other diseases of the skin, such 
as pemphigus, erysipelas, or those in which destructive pro- 
cesses have taken place and cicatrices formed. They are 
often congenital. 

Pathology. They are supposed to be due to retained 
secretion on account of the upper layers of the stratum cor- 
neum growing over the openings of the sebaceous glands, or 
to a non-development of the glands. Robinson thinks that 
some of them are due to " miscarried embryonic epithelium 
from a hair follicle or from the rete," while those "follow- 
ing pemphigus, erysipelas, syphilis, and lupus consist of 
fatty epithelium and cholesterine, the epithelium being often 
arranged in concentric layers around a central fat-nucleus." 



MOLLUSCUM CONTAGIOSTJM. 345 

Diagnosis. They must be differentiated from xanthoma. 
The latter are more of a lemon-yellow or buff color, and can- 
not be squeezed out when incised. Molluscum is sometimes 
mistaken for milium, but it is more prominent and hemi- 
spherical, and has a central punctum, out of which its con- 
tents can be squeezed without puncturing its top. 

Treatment. The treatment consists in pricking the top 
of the papule and pressing out its contents. To make sure 
of the destruction of the growth a drop of carbolic acid or 
iodine may be introduced into the cavity remaining. Hard- 
away advocates electrolysis as being the speediest and best 
treatment. If operative procedures are inadmissible, the 
skin may be caused to exfoliate by the use of green soap or 
salicylic acid, when the milia will be destroyed. 

Milk Crust. See Eczema. 

Mitesser. See Comedo. 

Mole. See Nsbvus. 

Molluscum Cholesterique. See Xanthoma. 

Molluscum Contagiosum (Mo 2 l-lu 3 sk r u 8 m ko 2 n-ta-ji 2 -os'- 
u 3 m). Synonyms : Molluscum epitheliale, seu sebaceum, 
seu verrucosum, seu sessile ; Epithelioma contagiosum ; 
(Fr.) Acne varioliforme, Ecdermoptosis. 

Symptoms. This is a contagious disease of the skin that 
occurs in most cases upon the face and in children and is 
characterized by the appearance of one or more rounded 
pearly white or pinkish discrete tumors, varying in size from 
a pin-head to large pea (Fig. 40). These tumors are waxy 
or opaque, and on top are slightly flattened, and show an 
umbilication or small depression, out of which the soft cheesy 
contents of the tumors can be squeezed. These tumors are 
at first very small, but gradually grow until they attain a cer- 
tain size, when they may remain unchanged for an indefinite 
period, or they may become inflamed, break down of them- 
selves, discharge their contents, and disappear either with- 
out leaving any trace or with a very slight scar. There are 
not infrequently scores of these tumors to be found on the 
same subject. They are commonly sessile, but may become 



346 



DISEASES OF THE SKIN. 



more or less pedunculated. The genitalia, breast, and 
scalp are affected next to the face in point of frequency, 
while the tumors may occur anywhere but on the palms and 
soles. 



Fig. 40. 




Molluscum. (After Allen.) 



Etiology. Children are far more often affected than 
adults. If adults are affected, it will usually be found that 
they are in attendance upon children who have mollus- 
cum. The bad hygienic conditions under which poor people 
live seem to predispose to the affection, as it is rare to meet 
with it among the well-to-do. There is little doubt that 
the disease is contagious. Though inoculation-experiments 
have failed in most instances, still there have been a few 



MOLLUSCUM COXTAGIOSTJM. 



347 



cases in which they have been successful. In the spring of 
1891 a child with molluscum contagiosum came into my 
service in Randall's Island Hospital, and within a few weeks, 
no attempt being made to destroy the tumors, there'were 
six cases in the wards. 

Pathology. The true pathological anatomy of these 
growths has not been settled, but the old idea that they 
spring from the sebaceous glands is no longer entertained. 
The rete seems to be the starting-point of the disease. One 
of the most characteristic features of the disease is the 
so-called " molluscum corpuscle," which is but a changed 
epithelial cell (Fig. 41). These appear, under the micro- 
scope, as large, ovoid, lustrous bodies, without nuclei, some 
being either wholly or partly contained in an epidermic 



Fig. 41. 




[Molluscum corpuscles. (After Kaposi.) 



envelope, and some being entirely uncovered. Several 
parasites have been declared to be the cause of the disease 
by different investigators, the latest candidates being the 
psorosperm of Darier in 1889, and the gregarine of Neisser 
in 1888. Torok 1 declares these to be merely artificial 
products of the methods used, "and is sure that the disease 
is not due to a parasite. 

Diagnosis. The appearance of the disease is so charac- 
teristic as to be diagnostic. It is most apt to be confused 
with milium, but if it is remembered that a milium has no 
central depression, while a molluscum has, the confusion will 

1 Monatshefte f. prakl. Dermat., 1890, x. 149. 



348 DISEASES OF THE SKIN. 

exist no longer. If they are taken for the vesico-pustules of 
variola, a scarcely probable occurrence, pricking their tops 
will at once show that they are not pustules, and if they are 
watched for a day or so it will be found that they remain 
unchanged. 

Treatment. The speediest way of getting rid of the 
tumors is to scrape them oif with the curette. To insure 
their not returning it is advisible to touch the base of each 
tumor with a drop of carbolic acid, or a stronger acid. Or 
it is sufficient to make a small slit in the top of the tumor 
with a scalpel, and squeeze out the contents, and touch the 
base with carbolic acid. 

Molluscum Epitheliale. See Molluscum contagiosum. 

Mulluscum Fibrosum. See Fibroma. 

Molluscum Pendulum. See Fibroma. 

Molluscum Sebaceum. See Molluscum contagiosum. 

Molluscum Verrucosum. See Molluscum contagiosum. 

Monilethrix. See Nodositas crinium. 

Morbilli (Mo 2 rb-i 2/ li). Synonyms : Rubeola ; measles. 

This is one of the contagious exanthemata, which is char- 
acterized by prodromata of marked catarrhal symptoms, 
such as conjunctivitis, coryza, and bronchial inflammation ; 
more or less fever, and constitutional disturbance ; and 
then, on about the third day, an eruption of small, red, flat 
papules that rapidly enlarge, and uniting with others form 
mulberry-colored little patches often of a crescentic shape, 
with areas of sound skin between. The eruption begins on 
the face and neck, spreading downward, from which it covers 
the whole body in about a day and a half. The fever begins 
to decrease on the second day of the eruption. The rash 
begins to disappear by the third or fourth day, and is gone 
by the ninth day. Furfuraceous desquamation follows the 
subsidence of the exanthem. Sometimes it is so slight as 
to be hardly noticeable, and it is never so marked as in 
scarlatina. 



MOBPHCEA. 349 

Diagnosis. The only dermatoses with which measles is 
apt to be confounded are an erythema, rubeola or German 
measles, variola, and the macular syphilide. But the catar- 
rhal symptoms ; the regular progression of the eruption 
from above downward ; and the crescentic patchy arrange- 
ment and dark color of the lesions are sufficient to differen- 
tiate it. In erythema we may have some constitutional 
disturbance, but it is of short duration ; the eruption is 
more pronounced on the trunk and extremities, and shows 
no order of progression ; the color of the eruption is a 
brighter red ; there is an absence of crescentic arrangement ; 
and very often an accompanying urethritis will suggest the 
ingestion of some of the balsams as a cause of the trouble. 
In rubeola there is not so much constitutional disturbance, 
less catarrhal complications, and a pronounced swelling of the 
glands of the neck. The eruption is usually a remarkably 
fine papular one, not so patchy as in measles. Variola in its 
early stage is sometimes difficult to diagnose from measles. 
Backache is usually a marked symptom in variola, its papules 
are smaller, harder, and more shot-like, and lack the crescen- 
tic arrangement of measles. The subsequent course of the 
disease is, of course, very different from that of measles. 
The erythematous syphilide affects the sides of the chest 
and the abdomen more than the face ; the rash lasts for 
weeks after any possible fever has passed ; its lesions have 
no definite arrangement and come out in successive crops, 
so that at the same time there will be present lesions of 
different age, and staining of the skin from those that have 
gone. 

Morbus Elephas. See Elephantiasis. 

Morbus Maculosus Werlhofii. See Purpura. 

Morbus Pedicularis. See Pediculosis. 

Morphcea (Mo 2 rf-e'a 3 ). Synonyms : Keloid of Addison ; 
Circumscribed scleroderma. 

A chronic, circumscribed hardening of the skin, forming 
an oval or irregularly shaped, smooth, lardaceous, yellowish 

16 



350 DISEASES OF THE SKIN. 

patch, looking as if mortised into the skin, and tending to 
spontaneous recovery. 

Symptoms. This is one of the rarer forms of skin dis- 
ease. It is a circumscribed scleroderma. It occurs either 
as circumscribed, variously sized, oval or irregularly shaped 
patches ; or in the form of bands. The most common is the 
patchy form. It begins as a congested, red, rosy, or lilac 
macule, which enlarges, pales in the center, becomes hard- 
ened, and assumes the form of a characteristic patch of the 
disease. This patch looks like a piece of old ivory or of 
lard set in the skin, being of a yellowish-white color. The 
color may be pinkish, yellow, brown, or even black. The 
skin over the patch is usually smooth, and easily pinched 
up. It may be wrinkled, or eroded in the center. It may 
be level with the surface of the skin, or raised above it, or 
sunken below it. Around it is a lilac border due to dilated 
vessels. When the patch is pinched between the fingers it 
feels firm, like leather. There may be but a single patch 
or a number of them. As a rule, the disease is unilateral. 
After a varying length of time it may disappear spontane- 
ously, although it may remain for a number of years. There 
are usually no subjective symptoms, and the disease remains 
unchanged until it disappears. In some cases it enlarges 
by new patches developing at the periphery of the old one 
and uniting with it. Exceptionally there may be some itch- 
ing or pain, and ulceration may occur. Sensation is gen- 
erally preserved. The band form is usually single, and may 
form a depressed sulcus or a raised ridge, looking much 
like a cicatrix. In addition to the bands there may be 
atrophic spots. 

The most common locations of morphoea are anywhere on 
the trunk, but specially on the breasts ; on the head and 
face in the parts supplied by the fifth nerve, and on the 
limbs. It is not infrequently associated with other nervous 
phenomena, and may occur along the course of a nerve, like 
zoster. Nettleship 1 has reported a case in the region of the 
first and second divisions of the fifth nerve with paralysis of 

1 Trans. Clin. Soc. Lond., 1882-3, xvi. 199. 



MORPHCEA. 351 

the intraocular branches of the third nerve, which in 
time had associated with it hemiatrophy of the whole of 
the left side of the head. There is no disturbance of the 
general health. The secretion of sweat over the patches 
may be normal, lessened, or absent. When the disease dis- 
appears it may leave no trace of itself, or it may be followed 
by pigmentation or even permanent atrophy not only of the 
skin but also of the muscles. A form of leprosy has been 
wrongly named morphcea. 

Etiology. The disease is a neurosis that occurs at all 
ages after the second year, but is uncommon after middle 
life. The victims of it are often neurotic. Prolonged 
worry or anxiety seems to predispose to it, and in some cases 
external local irritation seems to excite it. It is said that 
the band-form is most frequently seen in children, and that 
females are more often affected than males. 

Pathology. Owing to some defect in innervation cell- 
exudation occurs round the vessels, narrowing their lumen 
and obstructing the blood-flow, and leading to throm- 
bosis, and sometimes to a real rupture and effusion. Each 
atrophic spot near a growing patch is the base of a cone 
from which the blood-supply is cut off, the violet zone 
being due to collateral hyperemia round an anaemic area. 
(Crocker.) 

Diagnosis. Keloid may be mistaken for morphcea, but 
it has claw-like processes ; is more vascular and harder ; 
and lacks the old ivory color and the lilac surrounding zone. 
Some forms of ancesthetic leprosy have been spoken of as 
morphcea, but they are markedly anaesthetic, and this will 
be sufficient for diagnosis. Leueoderma is a pigment- 
change only, the skin being otherwise unchanged. 

Treatment. Unfortunately there is little or nothing to 
be done for the disease beyond attention to the general 
health of the patient. Arsenic may be of some benefit. 
Galvanism is perhaps the only local means that gives any 
promise of benefit, and that is but a feeble one. Further 
methods of treatment will be found under Scleroderma. 

Prognosis. We can tell our patient that there is a 
strong probability that the disease will be recovered from in 



352 DISEASES OF THE SKIN. 

time, but we should be careful about giving a positively 
favorable prognosis. 

Morpion is a name for the pubic louse. 

Morvan's Disease is a disease of the spinal cord which 
causes profound cutaneous lesions, such as ulceration, bullae, 
and fissures of the palmar side of the hands and fingers, 
and paronychia and necrosis of several phalanges. It is 
allied to, if not identical with, syringomyelia, which see. 

Morve. See Equinia. 

Moth Patch. See Chloasma. 

Mother's Mark. See Nsevus. 

Multiple Fungoid Papillomatus Tumors. See Mycosis 
fungoides. 

Myasis Externa Dermatosa is a dermatitis due to the 
penetration of the skin by certain kinds of flies, which lay 
their eggs under the skin. These subsequently hatch out 
and give rise to the dermatitis. 

Mycetoma. See Fungous foot of India. 

Mycosis Framboesiodes. See Dermatitis papillaris ca- 
pillitii. 

Mycosis Fungoides (Mi-ko'si 2 s fu 3 n-go 2 -i r dez). Syno- 
nyms : Inflammatory fungoid neoplasm ; Multiple fungoid 
papillomatous tumors ; Fibroma fungoides ; Lymphadenie 
cutanee; Granuloma fungoides; Eczema hypertrophicum 
seu tuberosum; Ulcerative scrofuloderma; Lymphodermia 
perniciosa ; Sarcomatosis generalis ; Multiple sarcoma cutis ; 
Fungoid dermatitis ; Beerschwamahnliche multiple Papil- 
largeschwiilste der Haut. 

A chronic progressive disease of the skin, characterized 
by the appearance, with or without an antecedent erythema- 
tous or eczematous stage, of fungating tumors, that tend to 
break down and ulcerate. It leads, through marasmus, to 
death. 

Symptoms. The many names that have been applied to 
this rare disease testify to the uncertainty of our knowledge 



MYCOSIS FUNGOIDES. 353 

of its proper place in the classification of skin diseases. It 
assumes so many forms that it is impossible in our limited 
space to give a complete picture of the disease. In some 
cases the first thing noticed is what appears to be a simple 
eczema, erythema, urticaria, or psoriasis in variously sized 
patches, and accompanied by marked pruritus. These 
lesions occur anywhere, and constitute the first stage of the 
disease. After some months, or two or three years or more, 
the patches become raised, glistening, and infiltrated, more 
deeply red, and pea-sized papules form. These disappear, 
and new ones form. This is the second stage, and may last 
months or years. Then the characteristic tumors form 
either by the papules enlarging and coalescing, or as tumors 
at once rising out of the sound skin, without antecedent 
erythematous stage. The tumors are oval, hemispherical, 
or irregular in shape, sharply defined, sometimes slightly 
pedunculated. They are of bright-red, bluish-red, or dark- 
red color. They are sometimes hard and elastic, sometimes 
soft and succulent. The epidermis over them is tense, thin, 
and glistening. They may be absorbed and disappear, new 
ones appearing ; or they may become necrotic and ulcerate. 
In size they vary from that of a pea to that of the fist. At 
first they occur only on the trunk, later they come any- 
where, and involve even the mucous membrane of the 
mouth. The itching and pain continue well into the tumor- 
stage, when they lessen. The lymphatic glands enlarge 
painlessly. The hair falls from over the tumors. The 
general health of the patient is undisturbed for a long time, 
but at last a general marasmus sets in and the patient dies, 
usually from an uncontrollable diarrhoea or some complica- 
tion on the side of the lungs. There has been but one case 
of recovery reported. 

Etiology. The majority of the cases have been women 
over thirty years old. The disease is held not to be con- 
tagious. Blanc 1 found in one case that there was a marked 
reduction in the white blood-corpuscles, their proportion to 
red being 1 to 130, instead of 1 to 350 or 500. This is 

1 Journ. Cutan. and Gen. -urin. Dis., 1888, vi. 256. 



354 DISEASES OF THE SKIN. 

about all that is known of the etiology of the disease. 
While much study has been given to the pathology of the 
affection there is no agreement among pathologists as to its 
essential nature. 

Diagnosis. The diagnosis of the disease in its early 
erythematous stage is very difficult, and probably cannot be 
made with certainty. There is something peculiar in the 
sharply circumscribed outline, and the chronicity of the 
eczematous patches, and an unusual location and pertinacity 
about the psoriatic patches that would suggest the possi- 
bility of mycosis fungoides. When the tumors develop, and 
the capricious manner of their coming and going is observed, 
the diagnosis is more evident. 

Treatment. Thus far nothing has been found to stay 
the course of the disease, except that Kobner reports a cure 
of a case by means of hypodermic injections of arsenic. A 
general tonic treatment is always indicated. Locally, pyro- 
gallol ; ichthyol ; mercurial ointment ; injections of car- 
bolic acid ; resorcin, and camphorated naphthol have been 
used and may be tried. The itching is most rebellious to 
treatment. The tumors, when not in great numbers, may 
be cut out, though the operation is of doubtful utility. The 
ulcerations that result from breaking down of the tumors 
must be treated on surgical principles. 

Mycosis Microsporina. See Chromophytosis. 

Myoma (Mi-o'-ma 3 ). Like most of the tumors, so this 
one concerns the surgeon more than the dermatologist. 
Myomata may be single or multiple. They are composed 
of muscular fibres, and vary in size from a split-pea to an 
orange. They are painful on pressure, and sometimes 
spontaneously. They are pink, red, or normal in color, 
disseminated, or aggregated into patches, though still retain- 
ing their individuality. The epidermis over them is un- 
changed. The single tumors may be sessile or pedunculated, 
and may attain the size of an orange. They have their 
seat most often on the female breasts, and on the genitalia 
of both sexes. If they contain a good deal of fibrous 
tissue, they are called jibro-myoma ; if they contain large 



NMVUS ABANEUS. 355 

bloodvessels, they form angio-myoma ; or, if the lymphatics 
are involved, we have lympliangio-myoma. Excision is the 
only thing that can be done for them. 

Myoma Telangiectodes. See Myoma (Angio-myoma). 

Myxcedema (Mi 2 x-e 2 d-e'ma 3 ). This is a constitutional 
disease with cutaneous symptoms. The skin becomes waxy 
pale ; yellowish ; shining in some places, dull and earthy- 
looking in others ; it is dry, scaly, exfoliating on the ex- 
tremities, sometimes ulcerated, and verrucose on the lower 
limbs. The fingers and toes are sometimes livid. There is 
partial or general alopecia, and deformity and fragility of 
the nails. There is a general cedematous swelling of the 
whole integument as well as of the mucous membranes, and 
this oedema does not pit on pressure. The swelling is most 
marked in the face. The skin about the eyes becomes puffed 
up so as almost to close the eyes. Cushions of fat fill the 
supraclavicular spaces. There is atrophy of the thyroid 
gland. The patient's intellectual faculties become dulled, 
the speech is slow, and the gait unsteady. 

The disease affects women far more often than men, and 
involves all parts of the body. There is an enfeeblement of 
mind, and a great lowering of the senses of touch, taste, and 
smell ; a torpidity of movement and of the digestive func- 
tions. It ends fatally either by marasmus or by complica- 
tions on the side of the internal organs. 

The diagnosis in the early stage is difficult ; when fully 
developed it could hardly be taken for anything else. The 
cause of the disease is unknown. 

Treatment. All the symptoms are removed by the use of 
thyroid extract or powder, improvement being rapid. When 
the treatment is stopped the patients after a time lapse into 
their former state, so that the administration of the thyroid 
has to be more or less continuous. 

Naevus (Ne'vu 3 s). A nsevus, strictly speaking, is a con- 
genital mark or growth in the skin, which may be either 
pigmentary or vascular. 

Naevus Araneus. See Telangiectasis. 



356 DISEASES OF THE SKIN. 

Nsevus Lupus. See Angioma serpiginosum. 

Nsevus Pigmentosus. Synonyms : Nsevus spilus ; ISTsevus 
pilosus ; Naevus verrucosus ; Nsevus lipomatodes ; (Ger.) 
Fleckenmal, Pigmentmal, Linsenmal ; Pigmentary mole ; 
Mother's mark. 

A congenital, circumscribed hyperpigmentation of the 
skin, often accompanied by a growth of coarse hair, and 
hypertrophy of the connective and fatty tissues. 

Fig. 42. 




Nsevus lipomatodes. 

Symptoms. These growths are closely allied to lentigo 
and chloasma, as a hypertrophy of pigment is a prominent 
feature of them. When they consist of pigment only, and 
are not raised above the surface of the skin, they are called 
ncevus spilus. When besides the pigment there is a hyper- 
trophy of the connective tissue, and they are raised and 
uneven, the name ncevus verrucosus is applied to them ; or 
ncevus lipomatodes if they are soft and contain fatty tissue ; 
if hair grows from either form, then we speak of ncevus 



N^VUS PIOMENTOSUS. 357 

pilosus. In color they vary from a light to dark brown or 
black. In size they vary from a split pea to an area large 
enough to cover the whole back. Most commonly they are 
of small size. They may be located anywhere, though most 
often on the face, neck, and back. There may be but one 
or two, or hundreds of them. They may have no special dis- 
tribution, or they may occur in streaks or bands. They may 
be unilateral or bilateral, and sometimes symmetrical. If hair 
is in them, it is coarse and stiff, and generally darker than 
that of the head. Sometimes large hairy moles bear a strong 
resemblance to the fur of animals. They grow in propor- 
tion to the growth of the individual, and cease growing 
when he has attained his growth. They are usually con- 
genital, but may be acquired, and are liable to undergo 
malignant change in advanced life. They give rise to no 
subjective symptoms. They are permanent growths. They 
rarely disappear of themselves. 

Etiology. To account for the appearance of these mal- 
formations we have only the theory of nerve-influence, and 
that is by no means satisfactory. Their popular name of 
mother's mark shows that the popular superstition agrees 
with the scientific theory. We can simply regard them as 
anomalies. 

Diagnosis. Moles differ from lentigo in being congeni- 
tal and permanent, and in a hypertrophy of connective 
tissue and a growth of hair being connected with them. 
The difference between hairy moles and hypertrichosis is in 
the substratum ; in the latter the underlying skin is otherwise 
normal. 

Treatment. We can destroy these growths and leave 
behind but little scar. If there is but a single pigmentary 
mole, it may be cut out. In this case it will leave a linear 
scar. It is generally better to destroy the growth by touch- 
ing it over carefully with nitric or glacial acetic acid. 
This is done by stippling, as it were, making a row of dots 
in this fashion — 



16* 



358 DISEASES OF THE SKIN. 

Electrolysis by multiple puncture, or by transfixing the 
mole in various directions, is a sure and speedy way. Hairy 
moles are best destroyed by electrolysis as in superfluous 
hair, only here a coarser needle must be used, as we are not 
so particular about a little scarring. The warty growths 
may be removed by a curette. 

Naevus Unius Lateris. This form of naevus is usually 
described as a variety of ichthyosis hystrix, but more prop- 
erly, it seems to me, it should be regarded as a form of 
nsevus pigmentosus. It occurs as streaks of raised, pig- 
mented, sometimes warty, sometimes papillomatous growths. 
They seem at times to follow nerve or vascular tracts, or 
perhaps the cleavage-lines of the skin. They may be uni- 
lateral and confined to one region, or they may be bilateral 
and on several regions. They may be congenital or develop 
in the first few years of life. They tend to enlarge until 
early adult life. The treatment is the same as that for 
naevus pigmentosus. 

Naevus Vascularis. Synonyms : Naevus vasculosus seu 
sanguineus ; Angioma ; (Ger.) Feuermal, Gefassmal ; 
(Fr.) Tache de feu, Tache vasculaire ; Port-wine mark ; 
Birth-mark ; Claret stain. 

Symptoms. These are composed mainly of vascu- 
lar tissue, and are congenital or appear during the first 
month of life. They are usually single, but may be mul- 
tiple. They vary greatly in size, shape, and color, but all 
possess one feature in common — they pale under pressure. 
They may be pin-head spots not raised above the surface of 
the skin, or they may form large, erectile, elevated, pulsat- 
ing tumors, or they may spread out so as to involve a large 
area. They may be pink, bright-red, dark-red, or even purple 
in color. When on the face they become more pronounced on 
crying, coughing, and the like. They may disappear spon- 
taneously ; increase in size during a few months or years ; 
or, most commonly, remain unchanged. According to their 
size they have received various names. The small, flat, or 
scarcely raised naevus composed of capillaries is called ncevus 
simplex or capillary naevus. This is the form very often 



NMVUS VASCULARIS. 359 

seen in children. It is not infrequent for it to disappear of 
itself after a while, either leaving no trace, or a delicate 
atrophic scar. When it is so large as to form a patch as big as 
the hand or larger, it is called ncevus flammeus or port-wine 
mark. The surface of this form is often uneven, and studded 
with small, erectile, vascular tumors, or, may be, pigmentary 
moles. It often becomes dark purple after exposure to cold. 
The large, erectile, pulsating tumors are called ncevus tubero- 
sus, angioma caver nosum, venous nwvus. They differ very 
much from the other forms in appearance and formation. 
Their surface is uneven and lobulated. This form is apt to 
increase in size, and may attain enormous dimensions. 

Nsevi may occur anywhere on the body, but are most fre- 
quent on the head and face. They may also occur upon the 
mucous membranes primarily or secondarily. The back, 
nates, pudenda, and lower limbs are said by Crocker to be 
the most common sites of the cavernous form. All forms of 
nsevi may be hardly perceptible at birth, but become grad- 
ually more evident afterward. 

Etiology and Pathology. Vascular naevi are prob- 
ably always congenital malformations, though their ap- 
pearance upon the skin may be retarded for some time. 
The simple capillary nsevi, which include the port-wine 
marks, are simply an increase in number and size of the 
capillaries. In the venous naevi we have also a new growth 
of connective tissue forming a mesh work, and they are sup- 
plied directly by an artery without the interposition of 
capillaries. Women are more prone to them than are men. 

Diagnosis. There can be no difficulty in diagnosis, ex- 
cepting that a nsevus may be taken for a telangiectasis. This 
error would be of little consequence, since the latter is simply 
an acquired ngevus, and differs chiefly in having a central 
red point from which the dilated capillaries radiate. 

Treatment. Electrolysis is the best means for destroy- 
ing the vast majority of these growths. The best way to 
use it in capillary nsevi and port-wine marks is by making 
multiple punctures in parallel rows, perpendicularly to the 
skin and down through its entire thickness. To expedite 
matters one may use either a circle of needles set in a 



360 DISEASES OF THE SKIN. 

handle, or a row of three needles. The negative pole is to 
be connected with the needle-holder, and the operation is 
to be conducted in the same way as in removing superfluous 
hair. By this method it is possible to destroy small nsevi en- 
tirely, and to diminish very much the unsightly appearance of 
large port-wine marks. As electrolysis necessarily destroys 
the skin, we must leave a scar. But this is less conspicuous 
than the nsevus, and if the operation is carefully done the scar 
is soft, smooth, and pliable. There is also much less danger 
of a deforming scar from the use of a single needle than from 
a group of them. Therefore this method is preferable, 
though more tedious. The punctures must not be made 
close together; at least a sixteenth of an inch should be 
left between them. After the naevus has been carefully 
gone over, it should be left alone for a couple of weeks or 
more for the full effect of the operation to be seen. It can 
be gone over again, and another interval of time allowed, 
and so on till the growth is destroyed as much as possible. 

Besides electrolysis we may use multiple scarifications 
obliquely to the skin. Or we may use the ethylate of sodium 
freshly prepared and applied to the absolutely dry skin, 
using a brush or glass rod. To avoid scarring only a small 
part of the nsevus must be attacked at a time. A crust will 
form, which must be left to come away of itself. Fuming 
nitric acid or the acid nitrate of mercury may be stippled 
over the growth. Or vaccination may be performed over 
it. Or multiple punctures may be made by means of a 
steel needle dipped in nitric or carbolic acid. Marshall 
Hal) advocates breaking up the naevus by introducing a 
cataract-needle close to the edge of the growth, pushing it 
across to the opposite side, then nearly withdrawing it, and 
again pushing it in at a little distance from the first punc- 
ture. But electroylsis is the best and most controllable 
method. 

For cavernous nsevus we may use electrolysis also, but 
here we pass the needle obliquely into the skin in the hope 
of striking the deep vessels. It is well, sometimes, to pass 
the needle from the edge deep under the nsevus and clear 
through to the other side, let the current pass for half a 



NETTLEBASH. 361 

minute, partially withdraw the needle, and again push it in 
another direction. Some prefer introducing two needles, 
connected each with one pole of the battery, in opposite 
direction. A platinum or gold needle must be used with 
the positive pole. Excision may be performed, but some- 
times this gives rise to alarming hemorrhage. Multiple 
punctures with a red-hot steel shoemaker's awl, or the point 
of a Paquelin or galvano-cautery heated to a dull red, are 
other good methods of treatment. It has been proposed to 
use a metallic plate perforated with a number of holes with 
which to exercise strong pressure upon the nsevus while the 
galvano-cautery is introduced through the holes. Injections 
of carbolic acid, perchloride of iron, alcohol, and the like, 
are effectual, but dangerous methods. Setons are not used 
as much as formerly. Compression by an elastic bandage 
is at times curative when the naevi are located over bony 
prominences. 

As many capillary naevi in children disappear in time it 
is advisable not to interfere with them at once, contenting 
ourselves with painting them with collodion and waiting 
until the child is old enough to desire their removal. Of 
course, if they are very unsightly we cannot wait, nor should 
we temporize with cavernous naevi. In children one works 
most comfortably by using an anaesthetic, but it is not abso- 
lutely necessary. Keloidal scars may be an unfortunate ac- 
cident in some cases. 

Prognosis. The prognosis should be guarded, and the 
cases carefully watched. All naevi may increase in size, 
though very many remain stationary. 

Naevus Verrucosus. See Ichthyosis hystrix and naevus 
unius lateris. 

Narbengeschwulst. See Keloid. 

Nerven Naevi. See Ichthyosis hystrix and naevus 
unius lateris. 

Nesselausschlag. See Urticaria. 

Nettlerash. See Urticaria. 



362 DISEASES OF THE SKIN. 

Neuralgia Cutis. See Dermatalgia. 

Neuroma Cutis is an exceedingly rare disease of which 
but few cases have been reported. Neuromata are small, 
flat, pinkish, or pale-red firm tumors firmly imbedded in 
the skin. They are painful spontaneously and on pressure. 
The pain may be paroxysmal in character. They are re- 
lievable by surgical interference with the nerve. 

Neuropathic Papilloma. See Ichthyosis hystrix. 

Nodositas Crinium. See Trichorrhexis nodosa. 

Nodosites Non-erythemateuses des Arthritiques. Brocq 

applies this name to cutaneous and subcutaneous tumors 
that he has met with in connection with the gouty diathesis. 
They are of two varieties. The first one he calls Epheme- 
ral cutaneous nodules. They occur upon the forehead and 
form ill-defined elevations of the skin, of small pea to hazel- 
nut size, and entirely painless. They are movable with the 
skin, though sometimes they are adherent. They appear 
first during the night and disappear within twenty-four 
hours. 

The second variety is the subcutaneous rheumatismal 
nodule. It forms a small tumor resembling a gumma. 
The skin slides freely over it in most cases. The color of 
the skin is unchanged. It is firm and elastic to the touch. 
Generally such tumors are painful on pressure, at times 
spontaneously. In size they vary from a pea to an almond, 
and they are sharply defined. They may remain for days 
or weeks, when they disappear, leaving no trace. They 
often come in successive outbreaks. Their seat of predilec- 
tion is about the joints, and upon the fibrous tissues that 
cover the superficial bones. They are generally discrete, 
and frequently very numerous. Their appearance often 
coincides with symptoms of pericarditis or pleurisy. Their 
treatment is that appropriate to the rheumatism that seems 
to be their cause, especially iodine and the iodides. 

Nodulus Laqueatus is that condition of the hair in which 
it seems to tie itself into knots. The hair is usually dry 



(EDEMA NEONATORUM. 363 

and curly. It is probably caused by handling of the hair, 
and does not occur spontaneously. 

Noli Me Tangere. See Lupus vulgaris. It has been 
used as a synonym for rodent ulcer. (Crocker.) 

Non-parasitic Sycosis. See Sycosis. 

Norwegian Itch. See Scabies. 

(Edema Cutis, Acute Circumscribed. It is a question 
whether this is a form of urticaria or not. It is certainly 
allied to it in the suddenness of its onset ; in the attending 
erythema, and digestive or other constitutional disturbances ; 
and in the character of its lesions. It differs from urticaria 
in being recurrent in the same locations ; in the shading off 
of the swellings into the surrounding skin ; and in being 
unattended by itching. It is prone to occur upon the face, 
and there often closes up one or both eyes in an enormous 
swelling ; or the lips so that the mouth cannot be opened. 
In some cases a history may be obtained of the occurrence 
of the same disease in other members of the family. It 
usually begins in early adult life and tends to recur. It 
may occur on the mucous membranes, causing suffocative 
attacks if the larynx is involved, and acute digestive disturb- 
ances if the stomach is affected. In the present state of 
our knowledge it is probably well to regard it as urticaria 
cedematosa. The treatment is the same as in urticaria, 
which see. (See Urticaria.) 

(Edema Neonatorum. This disease was formerly con- 
founded with sclerema, but is now separated from it. 

Symptoms. It is a rare disease, that begins upon the 
legs within the first three days of life. The oedema spreads 
upward along the thighs, shows itself upon the hands, 
then upon the genitals and back. It is hard and pits only 
on deep pressure. The skin is of a violaceous red, or more 
or less intense yellow, and feels cold. The infant is coma- 
tose ; its pulse is feeble ; its breathing labored ; and its cry 
sharp. A high temperature may exceptionally be present. 
Death usually results on account of some pulmonary affec- 
tion, or from collapse. Exceptionally, recovery takes place. 



364 DISEASES OF THE SKIN. 

Etiology. The disease occurs in feeble, ill-nourished 
children, in those prematurely delivered, or exposed to poor 
hygienic surroundings. 

Diagnosis. It differs from sclerema in being more 
limited to certain localities , in the skin being more livid 
from the first, and not so hard ; in affecting the dependent 
parts; and in lacking the stiffness of the joints. (Crocker.) 

Treatment. Though the prognosis is exceedingly bad, 
an attempt should be made to nourish the child as well as 
possible by artificial feeding ; it should be wrapped in 
flannel and kept warm ; and the limbs should be rubbed 
with warm oil, or camphorated alcohol, in such a way that 
the blood is forced toward the heart. 

(Eil de Perdrix. A soft corn. 

Oligamie. Anaemia. 

Oligosteatosis. Deficiency of fat-secretion. 

Oligotrichia. See Alopecia. 

Onychatrophia. See Atrophia unguium. 

Onychauxis (0 2 n-i' 2 k-a 4 x'i 2 s). Onychogryphosis (0 2 n-i 2 k- 
o-gr^f-o'-s^s). These are both hypertrophies of the nail 
either in length, breadth, or thickness ; or in all at the same 
time. When the growth is markedly forward, and the nail 
is much thickened, it is called onychogryphosis. The nail 
in these instances generally turns to one side after reaching 
a certain length, sometimes so much so that a big toenail 
may lie over the second and third toes. If the hyper- 
trophy is lateral, we are apt to have onychia, ingrowing 
toenail. The hypertrophied nail is rugous, but highly 
polished, brown, and there is often an accumulation of 
scales under it which at times gives rise to a bad odor from 
decomposition. The toenails are those most often hyper- 
trophied, but the finger-nails may be so affected. 

Etiology. Badly fitting boots and neglect of proper care 
of the nails are causes of onychauxis and onychogryphosis. 
They often arise without discoverable causes. They may be 
due to a congenital predisposition. They very often occur 



ONYCHIA. 365 

as part of some chronic skin or constitutional disease, such 
as eczema, psoriasis, leprosy, syphilis, and ichthyosis. The 
thickening may be due to disease of the matrix or to a 
thickening of the horny layer only. 

Treatment. The hypertrophied nail may be removed 
by mechanical means such as by the file, saw, or knife. The 
continuous use of salicylic acid sometimes will cause the 
thickened mass to fall off. The oleates of tin and lead ; 
the continuous wearing of rubber cots ; and liquor potassse, 
are also efficacious in softening the thickened mass of the 
nail. The action of all these agents is assisted by daily re- 
moving the softened layers by mechanical means. When 
the hypertrophy is but a part of some other disease, it will 
be benefited by the same means as will benefit the cause 
from which it arises. If it is due to an inflammatory disease 
of the nail-bed or matrix, that must receive attention. (See 
Onychia and Paronychia.) After the nail-deformity has 
been overcome it may return. 

Onychia (0 2 n-i 2 k'i 2 -a 3 ) or Onychitis (0 2 n-i 2 k-i'ti 2 s). By 
this is meant acute inflammation of the matrix and nail-bed. 
The end of the finger or toe is reddened and swollen, and 
there is more or less throbbing pain. The nail is lifted from 
its bed, more or less pus escapes from underneath it, and it 
is eventually shed. The inflammation often spreads to the 
adjacent parts of the finger, and then we have that condi- 
tion commonly called " whitlow." When the nail falls, a 
spongy nail-bed is left, often with exuberant granulations. 
Under proper treatment a good nail may be reproduced, 
though in many cases either a very much deformed one will 
result or one that diifers somewhat in appearance from the 
other nails. In some cases, instead of this phlegmonous 
form we have a dry inflammation that is known as onychia 
sicca. Here the nail is discolored, its edge thickened and 
brittle, its surface rough and more or less pitted. Eventu- 
ally the nail is shed. This condition is met with most often 
in syphilis. A chronic onychia is occasionally seen, and is 
one of the causes of onychauxis. 

Etiology. Onychia is due to traumatism or to some 
other disease of the skin, such as syphilis, eczema, psoriasis, 



366 DISEASES OF THE SKIN. 

parasitic diseases, dermatitis exfoliativa, and the strumous 
state. 

Treatment. The treatment of onychia varies with the 
stage of the disease and with the cause. Occurring as part 
of some general disease of the skin, the treatment appro- 
priate to the general disease will be beneficial to the ony- 
chia. Arising as an independent disease, or resulting from 
traumatism, the application of a 10 to 20 per cent, resorcin 
ointment or plaster will often abort the disease in an early 
stage. If the disease has gone on to suppuration, surgical 
procedures will have to be resorted to, such as splitting of 
the nail or its removal as a whole, and subsequent dressing 
with iodoform, aristol, or a bichloride solution. 

Onychomycosis (0 2 n-i 2 k-o-mi-ko r -si 2 s). This term means 
the invasion of the nail by a fungus, such as the trichophyton 
or achorion. For further information see trichophytosis 
and favus. 

Osmidrosis. See Bromidrosis. 

Osteosis Cutis. A case of osteosis of the skin of the 
foot was reported by Sherwell 1 in 1892. It involved the 
plantar surface of the left foot about the heel and on the 
fourth toe. The patches were of cartilaginous hardness, with 
horny surfaces studded with nodosities. The patches were 
fairly movable over the underlying parts. They were pain- 
ful when stepped on. The patient was a girl six years old. 
The patches were excised, but formed again within six 
months. A histological examination by Coleman 2 showed 
that they contained cancellous bone. 

Pachydermatocele. See Dermatolysis. 

Pachydermia. See Elephantiasis. 

Paget's Disease of the Nipple. Synonyms : Mamillaris 
maligna ; Malignant papillary dermatitis ; Epitheliomatose 
eczemato'ide de la mamelle (Besnier). 

1 Journ. Cutan. and Gen.-urin. Dis., 1892, x. 119. 
? Ibid., 1894, xii. 185. 



PAGET' S DISEASE OF THE NIPPLE. S67 

Symptoms. This is a rare disease of the skin that is 
named after Paget, who first described it in 1874. 1 

It usually occurs in women over forty years of age, and at 
first has the appearance of an eczema madidans ; that is, it 
presents " a florid, intensely red, raw surface, very finely 
granular, as if the whole thickness of the epidermis had been 
removed. From such a surface, on the whole or greater 
part of the nipple and areola, there is always a copious, 
clear, yellowish, viscid exudation." Besnier believes that 
its primary stage is a keratosis, which, under any irritation, 
assumes an eczematous appearance. The edge of the patch 
is sharply defined and slightly raised. Sometimes, instead 
of the raw surface, we have crusting, or even scaling. Telan- 
giectases may be seen here and there. After months or 
years marked induration is manifest, pinching up the patch 
imparting the sensation, as described by Mr. Morris, of " a 
penny felt through a cloth.'' Burning or itching is com- 
plained of, which makes the disease the more nearly resemble 
an eczema. But it does not yield to the ordinary treatment 
of eczema, and its border gradually extends. The female 
breast, usually the right one, 2 is the part most often affected, 
and there it always begins at the nipple, spreading thence 
over the areola and skin. After a few months, or not until 
twenty years, signs of scirrhous cancer appear. The nipple 
becomes more and more retracted and ulcerated. Shooting 
pains are complained of. Hard nodules develop in the raw 
surface or deep down in the skin. The mammary gland it- 
self may become affected. The disease in most cases is uni- 
lateral. The cancerous cachexia develops later with gan- 
glionic enlargements. Crocker and Pick have met with it 
on the scrotum and penis, and one case has been reported of 
involvement of the nipple of a man. 

Pathology. It is still an open question whether the dis- 
ease is malignant from the start, or, beginning as a simple 
inflammation, becomes malignant, just as we find epitheli- 
oma of the tongue developing upon a leucoplakia. Darier 

1 St. Bartholomew's Hospital Reports, vol. x. p. 83. 

2 Wickham : Maladie de Paget, Paris, 1890. 



368 DISEASES OF THE SKIN. 

and Wickham believe that the disease is due to psorosperms 
(see Psorospermosis). But their theory has not been gen- 
erally accepted as yet. 

Diagnosis. Though very important, it is exceedingly 
difficult at first to differentiate positively a case of Paget's 
disease from an eczema. Eczema of the nipple is very 
common during the childbearing period, while Paget's 
disease occurs most commonly after the climacteric. In 
eczema we do not have, as a rule, the raw granulating sur- 
face of Paget's disease, while we do have more variation in 
the course of the disease, exacerbations and seasons of ap- 
parent quiescence. In eczema the patch is not so sharply 
defined, and its border is not raised ; about it there are apt 
to be outlying pustules or vesicles, and there is not the 
papyrus-like induration. When the nipple becomes retracted 
and ulcerations take place, together with shooting-pains 
and enlarged lymphatics, the diagnosis is easy. It is said 
by some that psorosperms can always be found in the scabs 
scraped from the surface of a case of Paget's disease. 

Treatment. At the beginning, and while the diagnosis 
is still doubtful, the usual remedies for eczema should be 
tried. If these fail, as they will if the disease is not eczema, 
or if the right diagnosis is arrived at, powerful caustics must 
be used, if the disease is still superficial. We may use, as 
recommended by Darier, a solution of chloride of zinc, one 
in three, to produce an exfoliation of the diseased epidermis, 
and follow it with a mercurial plaster, alternating with 
iodoform or aristol. Or a chloride of zinc paste may be 
kept on, spread thickly on lint, for four to six hours, and 
the slough poulticed off or allowed to separate under wet 
boric lint, under oiled silk, as recommended by Crocker. 

The paste used in the Middlesex Hospital in these cases 
is made as follows : 

R. Zinci chlorid., 

Liq opii sed., 

Amyli, 

Aquae, |j ; ' 30l M. 

Ft. pasta. 

When there is ulceration, but not much induration, the 
surface should be thoroughly curetted and dressed antisep- 





7,50 

750 


3 jss ; 

3j; 


3 
301 



PAPILLOMA. 369 

tically. When nodules have formed, and there is marked 
induration under an ulcerated surface, the whole diseased 
surface must be freely excised or the breast removed entire, 
In fact, it seems to me best to amputate the breast as soon 
as the diagnosis is made, when the patient is past the 
childbearing period. If an operation or the use of caustics 
is unadvisable for any reason, relief to the pain and discom- 
fort may be had by dressing with a fuchsin solution 1 per 
cent, strength. 

Panaris Nerveux of Quinquaud belongs to that group of 
obscure diseases in which stand Morvan's disease and 
syringomyelia. It is characterized by swelling of the ex- 
tremities, slight redness, and attacks of intense pain, ter- 
minating in eight to fifteen days by fissure of the finger-end 
and fall of the nail. Sometimes the skin of the finger-end 
becomes sclerosed and atrophied. 

Brocq advises in its treatment the constant application of 
chloroform liniment, and of irritant lotions or frictions to 
the cervical region and along the course of the nerves sup- 
plying the parts. Internally, he advises the valerianate of 
ammonia or of quinine. 

Panaritium. See Paronychia. 

Panne Hepatique. See Chloasma. 

Papilloma (Pa 2 p-i 2 l-lo r ma 3 ). By this term is meant a 
papillary outgrowth from the skin. Such are common 
warts, verrucous eczema, papillary excrescences following 
ulceration, Kaposi's dermatitis papillaris capillitii, ichthy- 
osis hystrix, naevus unius lateris, and the like. The term is, 
therefore, of uncertain significance. Some authors have de- 
scribed papillomata apart from the above-designated dis- 
eases, and Hardaway reports at length a case of general 
idiopathic papilloma in a seven-months-old child. Mental 
defects have been noted in some of these cases. A muco- 
purulent secretion often is present, welling up between the 
papillae. The condition is a rare one. Under the name of 
papilloma area elevatum Beigel has described one of these 
rare cases. 



370 DISEASES OF THE SKIN. 

Papilloma Neuroticum. See Ichthyosis hystrix. 

Parakeratosis. Two forms of parakeratosis have been 
described, namely : Parakeratosis scutalaris 1 and paraker- 
atosis variegata. 2 

Parakeratosis Scutalaris. This case was that of a man 
forty-one years old. It occurred on the scalp, the whole 
of which, with the exception of a strip at the periphery, was 
covered by a thick, greasy crust that enveloped the hair in 
bundles. Some single hairs had on them cuffs of yellowish, 
white, waxy, horny substance, one inch or more long, that 
were in connection with the crusts on the scalp. The 
growth of the hair was not much interfered with. At the 
edge of the scalp was a hairless, red, dry, and rough strip. 

Parakeratosis Variegata. Of this form two cases are 
reported. Both were men. The eruption appeared on the 
thighs, chest, and neck, and later involved nearly the whole 
body, except the head, palms, and soles. The color of the 
eruption was red, forming an irregular network with small, 
sunken patches of normal skin. It was scaly and the skin 
was infiltrated. 

Parasitic Diseases. The diseases of the skin caused by 
well-accepted parasites may be divided into two classes : 
1. Those due to vegetable parasites. 2. Those due to animal 
parasites. 

Group 1 comprises favus, ringworm, chromophytosis, ery- 
thrasma, and pinta. These will be found described under 
their proper headings. 

Group 2 comprises a large variety of parasites. Scabies 
and pediculosis, due respectively to the acarus and pedicu- 
lus, are described at length in this book. Besides these we 
have — 

The leptus autumnalis, harvest-bug, or mower's mite, that 
bores its head into the skin, causes great itching, and induces 
violent scratching and consequent excoriations. 

1 Internat. Atlas of Rare Skin Diseases, No. 3. 

2 Monatsheft f. prkt. Dermat, 1890, x. 404. 



PARONYCHIA. 371 

The demodex folliculorum is described in relation with 
the comedo. 

The pulex penetrans, chigoe, or jigger, that resembles a 
flea, but penetrates under the skin with its head, sets up in- 
flammation and, perhaps, ulceration and gangrene, and has 
to be dug out of the skin with a blunt needle. 

The pulex irritans, or common flea, whose ravages are so 
well known as not to require description. 

The cimex lectularius, or common bedbug, attacks the 
skin for its food, punctures it, and at the same time injects 
an irritating fluid to increase the hyperemia and the food- 
supply. A wheal, or raised red spot with a central punc- 
ture, follows the bite, and a purpuric spot results. The 
irritation is relieved by any of the means serviceable in urti- 
caria. 

Gnats and mosquitoes and their effects are too familiar to 
all of us to require extended notice. 

Ixodes, or wood-ticks, the jilaria sanguinis and jilaria 
medinensis, the tcenia solium, and the echinococcus all find 
lodgment at times in the human skin. These parasites do 
not exhaust the list, but are the principal ones. 

Parchment Skin. See Atrophia cutis. 

Paronychia (Pa 2 r-o 2 n-i 2 k / -i 2 -a 3 ). This affection is popularly 
known as a whitlow, run-around, or ingrowing toenail. 
Ingrowing toenail results from the nail shoving or being 
shoved into the soft parts, either on account of disease of the 
nail itself, or of ill-fitting shoes, or of injury. The big toe- 
nail, at its inner or outer edge, is the most common site of 
the disease, though any toe may be affected, and even the 
finger may suffer. The furrow, fold, and bed of the nail 
all become inflamed, ulcerated, and exquisitely tender, dis- 
charging more or less pus. It is said to be more common 
in young people than in old, and far more frequent in men 
than in women. Paronychia of either the ulcerative or non- 
ulcerative form is frequently met with in syphilis. 

Treatment. Severe cases of paronychia most often find 
their way to the surgeon's hands. In syphilitic paronychia 
general anti-syphilitic treatment is required. In the non- 



372 DISEASES OF THE SKIN. 

ulcerative form mercurial ointment, diluted with one or two 
parts of diachylon ointment, may be used, or the mercurial 
plaster. In the ulcerative form the parts should be cauter- 
ized with nitric acid or a strong solution of acid nitrate of 
mercury, followed by water-dressings. Afterward the part 
may be dressed with iodoform or aristol. Bandaging, strap- 
ping with mercurial plaster, and the use of rubber cots are 
also useful methods of treatment. 

In ingrowing toenail the nail should be filed down the 
middle, or, if that does not relieve the pressure, it may have 
to be removed, in part or entire. The insertion of borated 
lint between the nail and the nail-fold, or using boric acid 
in powder first and some threads of lint or a little absorbent 
cotton to separate the parts, and strapping the toe with ad- 
hesive plaster, will also answer well. If ulceration has taken 
place, the ulcerated surface should be dressed with iodoform 
or aristol. If the ulceration should be covered with exu- 
berant granulations, they should be touched with the nitrate 
of silver stick. As a preventive of the trouble, wearing 
well-fitting shoes and keeping the nails clean and cut down 
the middle are the best means at our command. 

Paxton's Disease. See Tinea nodosa. 

Pediculosis (Pe 2 d-i 2 k-u 2 l-o / -si 2 s). Synonyms : Phthiri- 
asis ; Morbus pediculare ; Pedicularia ; Lousiness. 

Symptoms. There are three varieties of lice that infest 
the human species, namely, the pediculus capitis, pediculus 
vestimentorum, and pediculus pubis. Though they all be- 
long to one family, they differ among themselves, and have 
distinct regions which they invade. 

The pediculus capitis infests the head only, and of that the 
occipital region is the common seat of invasion. From there 
it generally spreads to the parietal region, which is one of 
the best places in which to seek for nits, and, maybe, all over 
the scalp. The lice cause irritation of the scalp both by their 
movements and by the insertion of their haustellum into 
follicles of the skin for feeding-purposes. The louse has no 
mandibles. There is no such thing as a louse-bite. They 
simply suck their nutriment by inserting their haustellum 



PEDICULOSIS. 373 

into the follicles of the skin. The victim scratches to re- 
lieve the itching and irritation, and this gives rise to a 
dermatitis of eczematous character with the production of 
large pustules. A fully developed and characteristic case 
shows the hair in the occipital region matted together with 
a sticky secretion and, maybe, blood-crusts, more or less 
eczematous lesions and scattered pustules over the whole 
scalp, enlarged lymphatic glands in the neck, and perhaps 
a few small pustules on the neck and face. When a patient 
presents himself with a pustular eruption on the neck, or 
with a number of large, crusted pustules scattered over the 
scalp, pediculosis capitis should always be suspected, and 
search made for the pediculi or their nits upon the occipital 
and parietal regions. Very often no pediculi can be found ; 
but if the disease is pediculosis, the nits will.be discovered 
in the localities mentioned. 

The pediculus vestimentorum, or body-louse, inhabits the 
seams of the clothing, where it lays its eggs, and which it 
leaves only for the purpose of feeding upon the skin. It 
inserts its haustellum into the follicles of the skin, and thus 
produces a small hemorrhagic spot, even with the suiface of 
the skin, which is a pathognomonic lesion of the disease. 
This feeding gives rise to itching, and the victim scratches 
to relieve it, thus producing a second symptom, excoriations. 
These have one peculiarity, which is that they are very apt 
to take the form of long, parallel scratch-marks, because the 
patient digs into his skin with all four nails at once. More- 
over, as the lice live by preference in the shirt-band at the 
back of the neck, these long scratch-marks are most often 
seen over the shoulders. Whenever they are seen we should 
suspect lice. Excoriations are also seen on the inside of the 
limbs in locations corresponding to the seams of the clothing 
and about the waist corresponding to the location of the 
waist-band. In certain individuals, besides excoriations and 
hemorrhagic specks, we will find ecthymatous pustules, ul- 
cerations, and, in very old cases, a great deal of pigmenta- 
tion, so that the skin appears as if affected with a general 
chloasma. Any of these symptoms, hemorrhagic specks, 
excoriations, and itching, which is incessant in pronounced 

17 



374 DISEASES OF THE SKIN. 

cases, should lead us to suspect lice, and a careful search of 
the seams of the clothing will reveal them, unless the patient 
has changed everything before coming to us. It must be 
remembered that the lice dwell both in the linen and wool- 
len clothing, and, in bad cases, in the bedding also. 

The pediculus pubis, crab-louse or morpion, has a far 
wider feeding-range than the other varieties. Though its 
favorite feeding-ground is the pubic region, it may be met 
with upon the hair of the abdomen, chest, axillae, beard, 
eyebrows and eyelashes. Itching, excoriations, and eczema- 
tous lesions are the symptoms it gives rise to, though the 
disturbance is not so great as that caused by the other forms 
of lice. It is the least common variety. It requires care- 
ful search and a sharp eye to discover the vermin at times, 
as they are almost transparent, and usually are attached to 
the hairs head downward, and close to the skin. Cobbold 
taught that the pediculus that inhabits the eyelashes was a 
distinct species, the pediculus palpebrarum ; but by most 
authorities the distinction is not made. In some cases, in- 
stead of red punctate marks, we find dull or slaty gray, or 
pale blue, lentil to split pea-sized macules scattered over the 
pubes, abdomen, extensor surface of the arms, axillae, and 
inside of the thighs. These are known as macules cceruleoe, 
or taches ombrees. They do not disappear on pressure. They 
last for a few days, and then disappear of themselves. To give 
rise to these spots there must be a predisposition on the part 
of the skin. Most of the few reported cases have been in 
debilitated subjecls. According to Duguet, 1 the macules 
are produced by the emptying of the contents of the salivary 
glands of the louse beneath the human epidermis. 

Etiology. These different varieties of pediculosis are 
due to different varieties of lice. The head-louse (Fig. 43) 
is about 2 mm. long and 1 mm. broad, with a triangular head 
and broad thorax and short legs. The body-louse (Fig. 44) 
is larger than the head-louse, being 2 or 3 mm. long, with 
a more oval head and longer legs with more developed claws. 
The pubic louse is broader and flatter than either of the 

1 Gaz. des Hop., 1880, liii 362. 



PEDICULOSIS. 



375 



others, with rounder head, longer, stronger, and more claw- 
like legs, resembling somewhat a crab (Fig. 45). The color 
of the lice is gray or white. They propagate with great 



Fig. 43. 



Fig. 44. 




Pediculus capillitii.— Male. 

(After Kuchexheister.) 




Pediculus corporis. 
(After Kuchexmeister. 



Fig. 45. 




Pediculus pubis. (After Schmarda 



rapidity, the young hatching out in six or seven days, and 
being capable within eighteen days of propagating their 
species. It has been calculated that two female lice might 



376 



DISEASES OF THE SKIN. 



Fig. 46. 



become the grandmothers of 10,000 lice in eight weeks' 
time. The pediculi deposit their eggs close to the scalp 
and secrete a glue-like substance that sticks the ova to the 
hair. There may be but one ovum on a hair, or many of 
them. The distance of the nit from the scalp shows the 
length of time that the disease has existed. As it takes the 
hair about a month to attain the length 
of three-fourths of an inch, if we find 
the nit that distance from the scalp we 
know that it was deposited at least one 
month before. The severity of the symp- 
toms to which the lice give rise will 
vary with the individual, some people 
being far more susceptible than others. 
Infection takes place from other people 
or from infested body or bed clothing. 
Women and children are the most 
frequent victims of pediculosis capitis; 
adults, and especially elderly people, of 
pediculosis vestimentorum. Pediculosis 
pubis is most frequently obtained from 
impure sexual intercourse, and is, there- 
fore, most common in young adults. 
Dirt and uncleanness favor all forms, 
though even the most cleanly may at 
times harbor vermin. 

Diagnosis. Pediculosis capitis needs 
to be diagnosticated from eczema. The 
characteristic location of its lesions upon 
the occipital region and nape of the neck, 
with its scattered and discrete large pus- 
tules over more or less of the scalp, 
should always suggest pediculosis ; then, 
if the lice or their ova are found by 
searching the hair, the diagnosis is es- 
tablished. Nits here, as elsewhere, are 
diagnosticated from epidermic scales by 
being located upon the side of the hair, while the scale 
has a hair passing through its center (Fig. 46). The nit, 




Ova of head-louse at- 
tached to hair. (After 
Kaposi.) 



PEDICULOSIS. 377 

too, is of a yellowish color, somewhat pear-shaped, with its 
larger rounded end upward, and it adheres closely to the 
hair, so as not to be readily removed. It is not always easy 
to distinguish pediculosis vestimentorum from pruritus cuta- 
neus, especially if at the time the patient presents himself 
he has clean clothes on throughout. Both may occur in 
elderly people, and both may last a long time with no other 
lesion than scratch-marks. In pruritus we may find evi- 
dences of atrophic skin-changes ; the itching is often parox- 
ysmal, and made worse by the patient becoming overheated. 
If we find the parallel scratch-marks over the shoulders and 
the hemorrhagic specks, we can make a positive diagnosis 
of pediculosis. From urticaria pediculosis vestimentorum 
differs in having hemorrhagic specks and in the parallel 
scratch-marks. Urticaria may complicate a pediculosis. 
Scabies differs from pediculosis in appearing by preference 
upon the anterior face of the wrists, upon the breasts in 
women, upon the penis of men, and about the umbilicus of 
both sexes. Its excoriations are not long, parallel scratch- 
marks, but small excoriations. If the lice or their ova can 
be found in any case, the diagnosis of pediculosis is made 
easy. Dermatitis herpetiformis differs from pediculosis in 
wanting the parallel scratch-marks and in the markedly 
grouped character of its lesions. There will often be found 
groups of vesicles scattered about the skin. There can be 
no difficulty in diagnosticating pediculosis pubis. Any 
itching about the pubic region should lead to an investi- 
gation, which, if carefully made, will reveal the pediculi or 
their nits. 

Teeatment. The most ready means of curing the dis- 
ease when in the hairy regions is to shave the hair off and 
make some emollient application to the scalp to cure the 
eczema. But this is not advisable, excepting in children 
and in men in hospitals, and is not necessary. The most 
speedy and practicable method in public practice is to soak 
the head or pubic region in raw petroleum or kerosene, with 
or without diluting it with sweet oil. This may be done 
night and morning for two days and the parts then washed 
with soap and water. This will effectually kill all the lice, 



378 DISEASES OF THE SKIN. 

and probably destroy the life of the ova. The latter must 
be removed for fear that they are not dead, and for this pur- 
pose we may use the fine-toothed comb to the hair or pull 
the hair through a cloth saturated with vinegar or dilute 
acetic acid, which will soften the gluey attachment of the 
nits. ~No attention is to be paid to the dermatitis until after 
the cause of it is removed, when it will rapidly get well 
under any simple treatment. In private practice, an infu- 
sion or tincture of staphisagria (larkspur seeds), or a 10 per 
cent, solution of carbolic acid, or a half to one per cent, solu- 
tion of bichloride of mercury, may be substituted for the 
petroleum. The bichloride should not be used if there is 
much dermatitis. The ointment of the ammoniate of mer- 
cury is efficient, but, as a rule, an ointment should not be 
used on hairy parts. Blue ointment is a well-known remedy 
for pediculosis pubis, but it is apt to set up a dermatitis that 
is undesirable. 

For pediculosis vestimentorum there is no use in making 
any application to the skin. The woollen clothes should 
be baked in a hot oven and the underclothing and sheets 
should be well boiled. If this cannot be done, or new clothes 
obtained, powdered sulphur or staphisagria may be powdered 
in all the seams of the clothing, and a 5 per cent, ointment 
of carbolic acid applied to the body. 

Pelade. See Alopecia areata. 
Peliosis Rheumatica. See Purpura. 
Pelioma Typhosum. See Maculae cserulese. 

Pellagra (Pe 2 l r -la 3 -gra 3 ). Synonyms: Risipola lombarda; 
Mai de la rosa ; Mai roxo ; Lombardian leprosy. 

Symptoms. But few cases of this disease have been 
reported in this country. Since the number of Italians is 
constantly increasing here it is important for us to be able 
to recognize the disease. It has prodromal symptoms of 
progressive weakness, intestinal catarrh, lassitude, giddiness, 
headache, and burning sensations in back, limbs, hands, 
and feet. These make their appearance in the spring, and 
shortly after an erythema affects the backs of the hands 



PELLAGRA. 379 

down to the articulation of the first and second phalanges, 
the backs of the wrists and forearms up to the elbow, the 
backs of the feet, if the person goes barefoot, the front of 
the neck and chest to the lower edge of the first piece of the 
sternum, and, in women and children, the forehead, nose, 
and cheeks — that is, all those regions exposed to the sun. 
The color is bright, dark, or livid red, and is not a simple 
erythema, as the color cannot be made to disappear com- 
pletely under pressure. The skin is often so swollen as to 
prevent all work. Bullae may form upon the affected parts 
and be followed by erosions. In a few weeks desquamation 
begins, but the skin continues discolored and thickened up 
to July or August, when a gradual decline of all the symp- 
toms takes place. During the winter the patient may appear 
quite well, but a relapse is pretty sure to occur during the 
next spring, and to recur each succeeding spring with ever- 
increasing severity of all the symptoms ; the patient emaci- 
ates, loses strength, develops grave cerebro-spinal neuroses, 
sinks into a typhoid state, and dies. The skin becomes 
atrophied, smooth, shining, cracked, or it may be thickened. 
There is loss of cutaneous sensibility and the erythematous 
redness gradually extends over the whole surface of the body. 
The average duration of the disease is five years. 

Etiology. The disease is endemic in northern and cen- 
tral Italy, especially in Lombardy, Venetia, and iEmilia ; 
in the southwestern part of France, and in the north part 
of Spain. It may occur anywhere. Women are most sub- 
ject to it, children least so. It seems to be a disease fos- 
tered by poverty, want and bad hygiene, and to be induced 
by an almost exclusive diet of decomposed or fermented 
corn or, possibly, other grains. Some cases have been 
traced to the drinking of spirits made from damaged maize. 
It is, therefore, similar in origin to ergotism. It is not 
contagious or hereditary. 

Diagnosis. A suspicion of a case being one of pellagra 
should be aroused whenever an erythema upon the exposed 
parts is met with in a person coming from the regions in 
which the disease is known to be endemic, especially if it is 
combined with more or less lassitude and hebetude. 



380 DISEASES OF THE SKIN. 

Treatment. The treatment of the disease is mainly 
hygienic and symptomatic. Crocker has faith in the effi- 
cacy of arsenic for adults, and frictions with chloride of 
sodium solution in children. 

Pemphigus (Pe 2 m'fi 2 -gu 3 s). Synonyms ; Pompholyx ; 
(Ger.) Blasenausschlag ; (Ital.) Pemfigo. 

A chronic disease of the skin characterized by the erup- 
tion of successive crops of bullae upon the apparently sound 
skin and with either transient or no antecedent erythema. 

At one time every bullous eruption was a pemphigus, but 
with more careful observation and study a number of bullous 
eruptions have been lifted out of pemphigus and estab- 
lished as distinct diseases. It is probable that this process 
of elimination will continue. In the meantime a considera- 
ble degree of uncertainty pervades our knowledge of the 
disease, both as to its symptomatology and etiology, and we 
can only stand and await further developments. While in 
this attitude we must have some sort of a chart to guide us, 
and it has been my object to draw its lines with as great 
sharpness as possible. 

The disease is a rare one in this country, only 183 cases 
being reported in a total of 123,746 cases in the statistical 
tables of the American Dermatological Association from 
1878 to 1887. 

Symptoms. It is usual to describe two varieties of pem- 
phigus, namely, pemphigus vulgaris and pemphigus folia- 
ceus. 

Pemphigus Vulgaris may begin with an outbreak of 
bullae, or there may be more or less constitutional disturb- 
ance before their appearance. The latter condition is more 
often seen in debilitated subjects, children, and old people, 
and consists in chilliness, nausea, and, perhaps, a rise of two 
or three degrees of temperature. These constitutional dis- 
turbances may occur before the appearance of each crop of 
bullae. The characteristic eruption is an outbreak of two 
or more up to a hundred or more pin-head-sized vesicles that 
in a few hours develop into tense, oval, hemispherical, 
prominently raised, fully distended bullae with translucent 



PEMPHIGUS. 381 

contents. The size of the bullae varies ; it may be but one- 
eighth of an inch in diameter, or, by the coalescence of 
several neighboring bullae, large, irregular ones of two or 
three inches in diameter may be formed. One distinguish- 
ing feature of these bullae is that they have no areola, but 
spring up at once from the seemingly healthy skin. Their 
contents soon become turbid, or perhaps purulent, and then a 
slight inflammatory halo may form. Rarely hemorrhage 
into the bullae occurs. The bullae do not tend to rupture 
spontaneously, but to dry up, and leave the dried cover as 
a crust. If they are ruptured accidentally, an excoriated 
place is left that heals more or less readily, according to the 
general condition of the patient. Some pigmentation may 
be left for a time to mark the site of the bullae. 

This eruption may take place anywhere, but affects par- 
ticularly the lower part of the face, the trunk, and limbs. 
It is usually bilateral, and may be roughly symmetrical. 
The life of the individual bulla is two to eight days ; but 
while one crop is disappearing a new one occurs, and the 
duration of the disease may thus be measured by weeks or 
months. Sometimes there is an interval of weeks or months 
between the outbreaks. In favorable cases a few crops ap- 
pear, and that is all, the patient making a good and com- 
plete recovery. In less favorable cases, or when the eruption 
is very extensive, frequent relapses and many excoriations 
take place, the patient's strength becomes exhausted by the 
constant drain upon his system and loss of rest on account 
of the discomfort of his condition ; he may die in a typhoid 
state, or of some intercurrent affection. A number of cases 
of death from the disease within two or three weeks have 
been reported, and to these the name of acute pemphigus is 
given. A few authorities have reported acute bullous erup- 
tions running their course in three to six weeks as acute 
pemphigus. Many of these cases were probably cases of 
bullous erythema, as in them a preceding erythema is noted 
in the reports of the cases. Most cases run a chronic course, 
extending over months or years. 

In rare instances a diphtheritic membrane may form at 
the site of the bulla, or, instead of healing taking place, a 

17* 



382 DISEASES OF THE SKIN. 

gangrenous process may be set up, with considerable destruc- 
tion of tissue, or hemorrhage may take place in some of the 
bullae. 

Neumann has described as pemphigus vegetans a bullous 
eruption in which healing does not take place, but the base 
becomes covered with sprouting granulations and assumes 
an uneven surface marked by furrows and secreting a thin 
fluid. The raw patches thus formed spread slowly at their 
circumference, and neighboring ones coalesce. The disease 
proves progressive; marasmus, and fiually death closes the 
scene. Most of the cases are in syphilitics. 

All the mucous membranes may be affected by pemphi- 
gus, and the excoriations that thus form in the mouth add 
greatly to the discomfort of the patient. The conjunctiva is 
not spared, and if attacked serious deformity results. 

Cases of pemphigus neonatorum have been reported from 
time to time, and epidemics of it have been described. These 
are so evidently septic in origin that they hardly admit of 
being classified under the heading of pemphigus. Careful 
reading of not a few outbreaks of contagious pemphigus 
reported in the German journals will convince one who is 
acquainted with the bullous form of contagious impetigo 
that a mistake in diagnosis had been made by the reporter. 
Still, until further evidence is forthcoming, it is probably 
advisable to allow that both of these varieties of the disease 
do exist. Pemphigus pruriginosus is another variety made 
by writers. It fits in quite well under Duhring's dermatitis 
herpetiformis. 

Pemphigus Foliaceus differs considerably from pemphigus 
vulgaris. It may begin as such or it may develop from 
pemphigus vulgaris. Behrend 1 teaches that the difference 
between the two forms is simply a matter of coherence be- 
tween the epidermis and corium, this being so slight in pem- 
phigus foliaceus that we have a flaccid bulla instead of the 
tense, fully distended one of pemphigus vulgaris. 

Pemphigus foliaceus is much the more rare variety of the 
disease, Crocker giving its occurrence as one in five thousand 

1 Vierteljahr. f. Derniat. u. Syph., 1879, vi. 191. 



PEMPHIGUS. 383 

cases. Its characteristic lesions are flaccid bullae, with 
opaque contents, that soon rupture and leave raw, moist 
surfaces with an edge of ragged epithelium. The fluid of 
the bullae changes its position with the position of the pa- 
tient, always seeking the most dependent part, and soon be- 
comes purulent. After the disease has existed some time 
the patient emits a sickening odor on account of the large 
amount of the raw surfaces of the ruptured bullae that are 
bathed with sero-pus. Affecting at first only a limited 
space, by degrees the disease spreads so that the whole body- 
surface becomes red and weeping, looking like eczema rub- 
rum, with crusts and areas of ragged epithelium. The palms 
and soles are often spared on account of the thickness of 
their epidermal coverings. When the skin is thus generally 
involved it is difficult to establish the fact of the occurrence 
of new bullae. The mucous membranes of the mouth and 
pharynx are affected in like manner, becoming converted 
into raw patches. The hair falls out ; the nails become 
thinner, brittle, atrophied, and, maybe, drop off; and ectro- 
pion is apt to result from contraction of the skin about the 
eyes. The mucous membranes are also attacked, which 
greatly adds to the patient's discomfort. 

The condition of the patient is most deplorable in these 
extensive cases; his skin is stiff and sore, and perhaps 
smarts ; and after months or vears he succumbs to the 
drain on his system, sinks into a typhoid state, and dies. 
During the early part of the disease there may be no consti- 
tutional disturbance. But eventually death is quite sure to 
result, if not from the disease, from some intercurrent affec- 
tion against which the patient is unable to offer any resist- 
ance. 

Etiology. We know very little about the causes of 
pemphigus. The tropho- neurotic theory of the disease 
offers us a cloak for our ignorance, and perhaps is, after all, 
the true one. Experiments have demonstrated that bullae 
can be made to form by operations on the spinal cord, and 
observation has shown that bullae do form in certain spinal 
diseases. Both sexes are equally subject to the disease. 
Children are more often affected than adults. The septic 



384 DISEASES OF THE SKIN. 

origin of certain bullous eruptions has already been spoken 
of under the heading of pemphigus neonatorum. Bullous 
eruptions are hereditary in some families, and in some sub- 
jects follow slight injuries to the skin. Chilling of the body 
seems to have been the exciting cause of some cases. Some 
have advanced the theory that an excess of ammonia in the 
blood or defective kidney-elimination is the cause of the 
disease. Attacks of the disease have been observed to occur 
with each new pregnancy in some women. 

Pathology. " Most authors regard the actual formation 
of the bulla as due to an inflammation of the papillary layer, 
with outpouring of fluid from the vessels ; but Auspitz calls 
it an akantholysis, or loosening of the prickle-cell layer, by 
the sudden escape of fluid from the vessels, destroying the 
young prickle-cells and lifting up the epidermis as a whole. 
Any inflammatory phenomena, he thinks, are secondary." 
(Crocker.) Micro-organisms have been found in the fluid 
both of the bullae of chronic and acute pemphigus, but their 
connection with the disease has not been satisfactorily 
demonstrated. 

Diagnosis. If we regard the pathognomonic symptoms 
of pemphigus vulgaris as fully distended bullae springing up 
out of the sound skin without any antecedent erythema and 
without inflammatory halo, and occurring in crops so as to 
run a chronic course, then little difficulty will arise in diag- 
nosis. A bullous erythema has bullae arising upon an ery- 
thematous base or with erythematous lesions elsewhere, and 
runs a comparatively acute course. Dermatitis herpeti- 
formis differs from pemphigus in the grouping and multi- 
formity of its lesions, and the great amount of itching that 
attends it. No matter how long it has lasted, it is seldom 
attended bv the constitutional disturbances that are met 
with in pemphigus chronicus. In bullous urticaria the bulla 
rises upon a wheal. The bullous form of impetigo conta- 
giosa will be quite sure to present the characteristic impetigo 
pustules upon the hands or face, and search will probably 
discover some child with impetigo with whom the patient 
has come into contact. Varicella bullosa occurs epidemi- 
cally, and runs a short course. 



PEMPHIGUS. 385 

Pemphigus foliaceus when in its early stage, and affecting 
but a small area, is readily diagnosticated by the occurrence 
of its flabby bullae, arising without antecedent injury. After 
it has lasted long enough to involve a large area it is with 
difficulty diagnosticated from eczema rubrum and dermatitis 
exfoliativa. In fact without the history of the case it is 
sometimes almost impossible to make the diagnosis. It may 
be differentiated from eczema rubrum by its crusts being made 
less of dried exudation than of epithelium, by the slighter 
amount of exudation, by the ragged look of some part of the 
disease, and by careful watching for and finding the large 
flaccid bullae which will be sure to appear if the case is one 
of pemphigus. Moreover, a universal eczema rubrum is very 
rare, and the itching is more pronounced. Dermatitis exfo- 
liativa differs from pemphigus in the absence of moisture 
and of bullae, and in the thinness of the exfoliated epidermis. 
Lichen ruber acuminatus is also perfectly dry and presents 
characteristic papules. 

Treatment. The drug upon which most reliance is 
placed in the treatment of this disease is arsenic. We may 
use Fowler's solution; or arsenious acid in pill-form, as the 
tablet triturate with piperina, or the Asiatic pill. Whatever 
form is given, it is advisable to begin with small doses and 
gradually increase them until the limit of tolerance is 
reached or the disease is controlled. Unfortunately it often 
disappoints us in its effects. Attention to diet and hygiene, 
and the general condition of the patient, with the judicious 
use of tonics, such as quinine, iron, and cod-liver oil, will 
often do as much, if not more, than arsenic to cure the 
patient. 

Locally, dusting-powders of oxide of zinc, starch, lycopo- 
dium, or bismuth in varying combinations ; lotions of lime- 
water, borax, zinc, liquor plumbi subacetatis, and the like, 
prove helpful in allaying irritation and discomfort. Lassar's 
paste is also a good application. Unna 1 recommends equal 
parts of linseed oil, lime-water, oxide of zinc, and chalk, 
both to dry up the bullae and prevent their return. Lini- 

1 Monatshefte f. prakt. Dermat., 1888, vii. 108. 



386 DISEASES OF THE SKIN. 

mentum calcis with one minim of creosote to the ounce is 
recommended by Hardaway. The continuous warm bath 
has afforded great relief in the Vienna hospitals. The 
bullae may be opened if they are troublesome. Alkaline 
and antiseptic mouth-washes will afford relief where the 
mucous membranes are affected. 

Prognosis. The chances of recovery are uncertain. 
While many cases of pemphigus vulgaris recover, relapses 
are the rule, and if the patient is not strong, or the disease 
has lasted a long time, a guarded prognosis should be made. 
Hemorrhagic, diphtheritic, or fungating bullae are of bad 
augury. Pemphigus vegetans and pemphigus foliaceus are 
almost invariably fatal. 

Perforating Ulcer of the Foot is an accident liable to 
occur in those in whom the nerve-supply to the foot is de- 
ficient, as in locomotor ataxia, syphilis, leprosy, and periph- 
eral neuritis. The most common location for the ulcer 
is at the metatarso-phalangeal articulation of the great or 
little toe, or the cushion of the great toe. It may be only 
on one foot, or both feet may be affected. The process is 
slow, beginning as a proliferation of the epidermis like a 
corn, under which suppuration takes place, and an ulcer is 
left. This goes deeper into the tissues until a sinus forms 
that reaches to the bone. The edges of the ulcer are hard. 
Usually there is little pain, though there may be hyperses- 
thesia of the surrounding parts. This painlessness distin- 
guishes it from a suppurating corn. The palms may be 
affected in the same way as the soles. The disease is very 
intractable, and must be managed on surgical principles, 
amputation of the whole or part of the foot being required 
in some cases. Death may result from the disease. 

Under the name of " Hand and Foot Disease " Hyde re- 
ports 1 three cases of ulcerations of the hands and feet that 
he regards as due to tropho-neurotic disturbances. In these 
cases, with or without functional disturbances, such as 
hyperidrosis and coldness of the hands and feet, bromidrosis, 
local anaesthesia, vertigo, faintness, and rheumatic pains, 

1 Phila. Med. News, 1887, li. 416. 



PERIFOLLICULITIS SUPPUREES. 387 

there were found various grades of dystrophia unguium, 
from roughness to onychogryphosis, tender and painful or 
insensitive maculations of the hands and feet, pigmentary 
patches on the palms and soles or the back of the hands or 
feet, or both ; different dermatoses, such as erythema, ec- 
zema, ichthyosis, local alopecias, hypertrichosis, symmetrical 
tylosis, with or without spontaneous exfoliation or recur- 
rence. After a time ulcerations formed on the hands or 
feet, or on both hands and feet. 

Periadenitis Sudoripara. See Abscess of sweat glands. 

Perifolliculitis Suppurees et Conglomeres en Placards. 

Under this lengthy title Leloir 1 has described and figured 
a rare disease of the skin which specially affects the backs 
of the hands. 

Symptoms. It seems to commence as a diffused red 
patch upon which develop small pustules, which itch slightly, 
or as small, red, more or less conglomerate, slightly itching 
elevations that form patches. The patches however formed 
are sharply defined, raised from 2 to 5 millimetres, round 
or oval, flattened, and of red, vinous, violaceous, or blue 
color. They vary in size from that of a ten-cent piece to a 
silver dollar, and are often crusted. When the crust is re- 
moved the exposed surface is smooth or mammillated, but 
never papillomatous ; and riddled with a number of pin-point 
to pin-head-size openings, corresponding to glandular orifices, 
many of which are closed with a plug of greenish, dried pus. 
Besides these openings there are a number of greenish 
points that are ready to become such whenever the epider- 
mis over them is removed. At a more advanced stage the 
openings form small pin-head ulcers. By compression of 
the patch these openings give vent either to a drop of pus 
or serous fluid, or little, elongated, vermicelli-like whitish 
masses. In still more advanced cases the patches become 
more elevated, fluctuation manifests itself, and a sero-pus 
may be expressed. The patches are usually single, but may 
be multiple. The back of the hand and wrist are the usual 

1 Annal. Derm, et Syph., 1884, v. 437. 



388 DISEASES OF THE SKIN. 

locations of the disease, but it may occur upon the dorsum 
of the foot or the outer side of the thigh, or be disseminated, 
but chiefly located on the extremities. The course of the 
disease is acute. It is fully developed in eight days ; it then 
continues a week or two and disappears in about twelve 
days more. If badly treated, it may last longer, and be 
followed by a papillary condition. It is unattended by sub- 
jective symptoms, except slight itching. It leaves either 
no trace of itself, or a delicate superficial cicatrix that dis- 
appears of itself, or a slight staining that soon fades. The 
hair is unaffected, though the disease may involve its folli- 
cles. 

Pathology. The disease is a purulent inflammation of 
the skin follicles, specially of the lanugo hairs, and the pilo- 
sebaceous follicles of regions deficient in true hairs. It is 
possibly microbic in origin. 

Diagnosis. The disease is diagnosticated from tricho- 
phytosis by its more rapid course, and recovery under sim- 
ple treatment ; by the hair being unaffected ; and by the 
absence of the trichophyton in the hair. Anthrax differs 
from it in the more pronounced character of its local and 
general reaction, its central core, and inflammatory indura- 
tion. Tuberculosis verrucosa cutis is much slower in its 
evolution, is serpiginous, and does not yield to simple treat- 
ment. Eczema differs from it in not having such sharply 
marked borders ; in wanting the characteristic openings 
and livid tint ; and in having more pronounced itching, a 
mucous, sticky discharge, and a comparatively long duration. 

Treatment The treatment is simple and consists in 
squeezing out the pus once a day, bathing the part for half 
an hour in warm carbolized water or a solution of boric acid, 
and covering with an antiseptic dressing. If papillae have 
formed, they should be scraped off, and the surface touched 
with nitrate of silver. In some obstinate cases it may be 
necessary to scrape out the whole patch. 

Perionyxis. See Paronychia. 

Perleche (PeV-le 2 sh). According to Brocq, this is a dis- 
ease occurring in infants and affecting the commissures of 



PIEDRA. 389 

the lips. Their epithelium is pale, macerated, desquamat- 
ing, while the skin underneath is red and slightly inflamed. 
Sometimes fissures will form that are painful, and may bleed 
when the patient widely opens his mouth. The inflamma- 
tion may spread to the neighboring regions. It runs a course 
of two or three weeks, but is subjected to relapse. It is con- 
tagious, and is due to a streptococcus. 

It bears a close resemblance to the fissures of the lip met 
with in syphilis, but is marked by an absence of all other 
symptoms of syphilis. 

The treatment consists in touching the diseased parts with 
the sulphate of copper or alum, or an antiseptic solution, and 
in carefully looking after the nursing-bottles. 

Pernio. See Dermatitis calorica. 

Pfundnase. See Rosacea. 

Phagmesis. A rare condition in which it is said that 
feathers instead of hair adorn the body. 

Phtheiriasis. See Pediculosis. 

Pian. See Yaws. 

Pian Ruboide. See Dermatitis papillaris capillitii. 

Piebald Skin. See Leucoclerma. 

Piedra (Pe-ad'ra 3 ). Synonyms: Tinea nodosa ; Tricho- 
mycosis nodosa. 

Symptoms. This disease, or deformity of the hair, is 
said to occur only in Cauca, one of the United States of 
Colombia, and was first described in 1874 by Dr. N. Osorio, 
of the University of Bogota. It consists in the occurrence 
along the shaft of the hair of from one to ten small dark- 
colored nodes which are very hard and gritty, and rattle 
like stones when the hair is combed or shaken. The stony 
hardness of the nodes gave the disease its name " Piedra/' 
which is the Spanish for " stone." These nodes are always 
placed at irregular intervals along the hair- shaft, beginning 
at about half an inch from the point of exit of the hair, the 
root being unaffected. The disease occurs most commonly 
in women, men being rarely aifected, and it is the head-hair 



390 DISEASES OF THE SKIN. 

alone which exhibits these nodes. The disease is non-con- 
tagious, and is met with only in warm valleys. 

Etiology. Dr. Osorio thought that the nodes were pro- 
duced by an agglomeration of epithelium in certain parts of 
the hair. Mr. Morris 1 believes it is due to the use of a pecu- 
liar mucilaginous linseed-like oil, which is used particularly 
by the native women to keep their hair smooth and shiny. 
Another theory is that it is due to the use of the water of 
certain stagnant rivers which is very mucilaginous. Heat 
seems essential for its production, as the employment of 
either of these fluids will not cause the disease in cold 
climates. 

Microscopical examination of the affected hair shows 
that the nodes consist of a honeycombed mass of pigmented 
spore-like bodies, the whole mass arising from one cell which 
sends out spore-like columns radially in all directions. As 
soon as the cells have reached a certain size, they seem to 
alter their shape, become darker in color, and form a pseudo- 
epidermis. It is, therefore, a fungous growth. The nodes 
were found to be very hard to cut, and when considerable 
force was used they broke. 

Diagnosis. Piedra differs from trichorrhexis nodosa in 
the stony hardness of the nodes, in its occurring principally 
upon the head-hair, in its probable etiology, and in the 
microscopical appearances it presents. 

By the use of hot water the nodes can be entirely 
removed. 

Pigmentary Mole. See Nsevus pigmentosus. 
Pigmentgeschwulst. See Melanotic sarcoma. 
Pigmentkrebs. See Sarcoma. 
Pigmentmal. See Naevus pigmentosus. 
Pimples. See Acne. 

Pinta (Pent'a 3 ). Synonyms : Mai de los pintos ; Tinna ; 
Caraate or cute ; Quirica ; Spotted sickness. 

1 Lancet, 1879, x. 407. 



PITYRIASIS ROSEA. 391 

This disease occurs only in southern Mexico, Panama, 
and South America. 

Symptoms. According to Crocker, from whose work 
this account is drawn, it consists of scaly spots varying in 
color, shape, number, and size. They show themselves first 
on the uncovered parts, but may affect any or all of the 
cutaneous surface. The disease spreads by the peripheral 
extension of old patches and the formation of new ones. 
The patches are round or irregular in shape, sharply or ill 
defined, and of black, gray, blue, red, or dull-white color. 
The red and white patches are deeper-seated than the 
others, being located in the rete and coriurn. The patches 
may be of uniform color or of different tint, but do not 
change their color after they have once formed. They are 
scaly and usually feel rough and dry. The hair grows gray 
and falls. There is some itching, and a bad odor emanates 
from the patient. The course of the disease is chronic and 
shows no tendency to recovery. 

Etiology. The disease is contagious and its spread is 
favored by dirt and neglect. It is most common in the poor 
natives of Indian stock. It is of fungous origin, and, in 
fact, seems to be allied to chromophytosis. 

Treatment. The treatment is the same as for chromo- 
phytosis. 

Pityriasis Maculata et Circinata. See Pityriasis rosea. 
Pityriasis Parasitaire. See Chromophytosis. 
Pityriasis Pilaris. See Keratosis pilaris. 

Pityriasis Rosea (Pi 2 t-i 2 ri 2 -a r sis). Synonyms : Pityriasis 
maculata et circinata ; Herpes tonsurans maculosus (Hebra) ; 
Roseola pityriaca (Barduzzi) ; Pityriasis circine* et margine 
(Vidal) ; Pityriasis rosee (Gibert) ; Erytheme papuleux 
desquamatif. 

An acute disease of the skin characterized by an erup- 
tion of rosy-red macules that enlarge into dry, scaly, oval, 
or annular patches with rosy -red peripheries and chamois- 
yellow, wrinkled centers; it runs a definite course and ter- 
minates in recovery. 



392 DISEASES OF THE SKIN. 

Symptoms. Though Gibert described pityriasis rosea 
as early as 1868, the disease is but little known in this 
country, not because it does not occur, but because it is not 
recognized. It is one of the rarer skin diseases. Most 
writers tell us that its outbreak is preceded by slight consti- 
tutional disturbances, such as malaise, loss of appetite, and 
headache. These symptoms, in my experience, have been 
as conspicuous by their absence as in the case of impetigo 
contagiosa. The eruption itself most often begins upon the 
upper part of the chest a little above the breasts, or, accord- 
ing to Brocq, 1 at the level of the waistband, anteriorly and 
a little to one side, where he locates what he calls the 
n primitive patch." The primary lesions are miliary or 
small papules of pale-red color, surrounded by an erythema- 
tous zone. These soon enlarge into rosy-red, slightly raised 
macules, and slowly increase peripherally into oval or 
rounded patches with well-defined borders raised somewhat 
higher than the centers. When the patches have attained a 
diameter of half an inch or more the centers begin to clear 
up by becoming of a yellow, old-parchment color ; scaly and 
shiny, while the border is pale-red. Later the center may 
disappear and rings only remain, or if two or more patches 
meet at their borders irregular gyrate figures may be formed. 
All the lesions do not attain the same degree of development, 
and in a well-developed case lesions in all stages will be 
found. The lesions are slightly scaly from the commence- 
ment, and the furfuraceous desquamation continues until 
the faint mark left by the lesion disappears. Itching, 
usually slight in amount and only when the person is warm, 
is the only subjective symptom. Sometimes it is severe. 
The eruption is most marked upon the neck, infra- and supra- 
clavicular regions, sides of the chest, and shoulders ; it may 
be marked also on the abdomen and buttocks. The whole 
body may be involved, but the hands and feet are usually 
spared, and it is uncommon on the face. After some three 
to six weeks the disease tends to spontaneous recovery, 
although it may last for two months. 

1 Annal. Derm, et Sypk., 1887, viii. 615. 



PITYRIASIS ROSEA. 393 

Etiology. We know nothing about the causes of the 
disease. It affects all ages and both sexes. Crocker thinks 
that it is most common in children. Most of the cases I 
have seen have been in young adults. This difference may 
be accounted for by the fact that he has a large children's 
dispensary service. Some cases seem to be due to over- 
heating of the skin by wearing too heavy underclothing. The 
disease seems to occur epidemically in some instances, and 
cases are apt to present themselves in groups. Contagion 
has not been established. Bazin regards it as arthritic. It 
may be parasitic, but as yet the parasite awaits discovery. 
Yidal 1 describes a parasite that he names the microsporon 
anomceon, as found in pityriasis circine et margin^, a disease 
probably the same as pityriasis rosea. Hebra regarded it 
as a manifestation of trichophytosis, and some authorities still 
think that some cases are diffused ringworm. 

Diagnosis. Pityriasis rosea must be differentiated from 
the early circinate, scaling, macular syphiloderm ; annular 
psoriasis ; seborrhcea sicca corporis ; and disseminated tri- 
chophytosis. The one most distinguishing feature of pity- 
riasis rosea is the wrinkled old-parchment yellow of the 
center of the ring. This is absent from the lesions of all 
the other diseases with which it is likely to be confounded. 
The syphilide is of a less bright-red color, and there surely 
will be some other evidence of syphilis to guide us. Psori- 
asis is far more scaly ; the scales are of a white color ; the 
tips of the elbows and the anterior face of the knees will be 
specially affected ; and typical psoriatic patches will be found 
somewhere. Seborrhcea corporis occurs upon the middle 
sternal and inter-scapular regions particularly ; the patches 
have a greasy feel ; the scales are thicker than in pityriasis 
rosea; and the lesions show little tendency to spontaneous in- 
volution. In trichophytosis the fungus is readily found under 
the microscope, which is a decisive test. Apart from that, 
ringworm does not spread so rapidly, nor involve such wide 
areas. 

Treatment. Pityriasis rosea is a self-limited disease, 

1 Annal. Derm, et Syph., 1882, iii. 22. 



394 DISEASES OF THE SKIN. 

and recovery is sure to take place in a short space of time. 
Though treatment seems not to have any marked effect on 
the disease, we may use salicylic acid in vaseline, ten to 
twenty grains to the ounce, or boric acid or mild sulphur 
ointment, or content ourselves by allaying the itching with 
lotions of carbolic acid (ten grains to the ounce), calamine, 
oxide of zinc, and the like. 

Pityriasis Rubra. See Dermatitis exfoliativa. 

Pityriasis Rubra Pilaris. This disease was first described 
by the French writers. The following account is abstracted 
from an admirable paper by Besnier. 1 

It has been confused with lichen pilaris, psoriasis, lichen 
ruber and lichen planus, and pityriasis rubra. Several cases 
of lichen ruber reported in this country have been declared 
by the French to be cases of the disease under consideration, 
as well as the lichen psoriasis of Hutchinson. Kaposi regards 
it as the same as lichen ruber. It is probable that the two 
are identical. 

Symptoms. A typical case has three principal elements : 
1. Asperities of the follicular orifices; 2. Desquamation; 
3. Roughness of the skin with exaggeration of its folds. 
The disease generally begins suddenly, without prodroma, 
but there may be some malaise, nervousness, insomnia, 
hyperesthesia of the finger-ends, formication, and the like. 
These prodromata are of short duration, and rarely cause 
the patient to go to bed. The uncovered parts are usually 
first affected with the eruption, but it may appear primarily 
upon the trunk or extremities. The initial lesion may be a 
simple exfoliation ; an erythema ; a scaling erythema ; a 
fine but scanty furfuraceous desquamation ; a shiny redness 
with pityriasis; desquamation of nail-bed, or fragility of 
nail. However beginning, the more pronounced form ap- 
pears in a certain number of days or weeks, and may 
develop or abort at any point, or be limited to any region, 
or involve the whole body. When fully developed a patch 
or the whole skin, as the case may be, presents the following 

1 Annal Derm, et Syph. , 1889, x. 253 et seq. 



PITYRIASIS RUBRA PILARIS. 395 

characteristics : It is covered with elevations that are gen- 
erally conical, but may present great diversity of shape. 
They may be discrete or coalesce. They may be so small 
as to be seen only by the aid of a microscope, or elevated 
many millimetres above the surface, with corresponding 
diameter. They are scaly, and vary in color from a silver- 
white or gray to a bright or opaque red, red-brown, or rosy 
yellow. Their summits may be flat, uneven, cone-shape, or 
truncated, giving issue to a hair broken off at a little dis- 
tance above the surface of the skin, and, may be, sheathed 
by a corneous or sebaceo- squamous case. Instead of a hair 
protruding, it may form only a small comedo-like spot at the 
center of the summit, or it may be wanting, or it may seem 
to exist alone, giving to the region the appearance of a badly 
shaven beard. Sometimes the cone presents a crater, at the 
bottom of which is a black point, a punctured scaly plate, 
or a psoriatic point. When several elevations coalesce their 
borders disappear and form a squamous patch, showing the 
central points and the associated pilary cones. The skin is 
scaly, dry, hard, rough like a file, and presents a "goose- 
skin" appearance. The scales maybe scraped off without 
any loss of blood. The disease is generally symmetrical, 
but the lesions may be disseminated without order, or in 
irregular lines, groups, or islands, or may unite in tessellated 
areas. The cone-like elevations do not occur on the scalp, 
and are rare on the soles and palms. In these locations the 
disease takes the form of abundant desquamation upon a 
reddened base. All other regions may be affected, the cones 
forming about the follicles of the skin, especially about the 
hair follicles. The backs of the phalanges of the fingers 
are nearly always affected, appearing rough, uneven, and 
covered with patches of characteristic papules. Some 
variations from the type are encountered in different re- 
gions, but characteristic types will be found somewhere on 
the body. The hair may fall, and the nails may be de- 
formed, opaque, and raised by an accumulation of scales 
under them. 

The general condition is unaltered, and little, if any, dis- 
comfort is experienced. The duration of the disease is 



396 



DISEASES OF THE SKIN. 



indefinite, and relapses are the rule. Second and subse- 
quent attacks may be shorter than the first. 

Etiology. The etiology of the disease is obscure. It 
occurs at all ages, and in both sexes, but most often in 
infancy or youth, and in males. Many causes have been 
assigned to it, such as cold, excesses, rheumatism ; but none 
of these can be definitely said to be the cause. 

Diagnosis. The disease is to be diagnosed from ichthy- 
osis in not being congenital ; in attacking by preference 
the joints, scalp, face and neck ; and in its spontaneous 
recovery for a time. From dermatitis exfoliativa by its 
benign course ; its location about the follicular openings ; 
and by the thick scaling of the palms and soles. From 
lichen ruber the diagnosis is difficult, the two being con- 
sidered by many as identical. Hebra (Jr.) has made a care- 
ful study of the two diseases, 1 and we give here his table of 
differential diagnosis between them : 



Pityriasis Rubra Pilaris. 

1. Develops in the epidermis. 

2. Efflorescences bear scales from the 

beginning, and often consist of 
accumulations of epidermic 
scales alone which can readily 
be scratched off. 

3. Efflorescences limited to follicle 

mouths, especially those of hair 
follicles. 

4. Extensor surfaces of the extremi- 

ties especially affected. 

5. Microscopically consists of thick- 

ening of the epidermis, with 
lengthening of the inter-papil- 
lary projections of the rete mu- 
cosum in certain places. 

6. Color of efflorescences scarcely 

differs from that of the skin 
at the beginning. Afterward 
becomes rosy or brownish red 
from consecutive hyperemia.] 

7. Roughness of the extensor surfaces 

of the extremities, and satin-like 
smoothness on the trunk, with 
fine scales. 

8. No accompanying subjective symp- 

toms. 

9. No implication of the general 

health. 



Lichen Ruber Acuminatus. 

1. Develops in the cutis. 

2. From the beginning they are 

smooth and glistening. Scales 
form only late in the disease. 



3. Are not limited to the follicle 

mouths. 

4. Flexor surfaces more affected than 

extensor surfaces. 

5. Marked collections of round cells 

in the papillary layers of the 
corium. 



6. From beginning a bright red, be- 
coming darker, and may change 
to deep rusty -brown. 



Everywhere thickening and 
roughness of the skin in- 
creasing with the age of the 
disease . 

Unbearable itching, great burn- 
ing, restlessness, and jerking 
movements of the limbs. 

Fever, oedema (especially of 
lower extremities), albumi- 
nuria, sleeplessness, general 
prostration, and loss of weight. 



1 Monatshefte f. prakt. Dermat., 1889, x. 101. 



PITYRIASIS SIMPLEX. 397 

Pityriasis Rubra Pilaris. Lichen Ruber Acuminatus. 

10. Spontaneous recovery, or chron- 10. Often ends in death, always at- 

icity without danger to the pa- tended with marasmus, 

tient. 

11. Cured by purely local means, 11. Cured, if at all, by constitutional 

though often obstinate. • treatment, as with arsenic. 

Unna's ointment of mercury 
and carbolic acid good. 

12. Little or no pigmentation left. 12. Deep-brown, even blackish-brown, 

pigmentation left which may 
last for months. 

13. Does not affect the mucous mem- 13. Affects mucous membranes, es- 

branes. pecially of mouth and vagina. 

Psoriasis at times bears a strong resemblance to pityriasis 
rubra pilaris, but it seeks the elbows and knees particularly ; 
its scale is larger ; and it is not a follicular disease, never 
presenting comedo-like plugs, broken-off hairs, or little ele- 
vations. 

Treatment. No satisfactory treatment has been found, 
but the remedies applicable to psoriasis or to ichthyosis can 
be used with advantage. Like in that disease, an attack 
may be overcome, but no assurance can be given against a 
relapse. Thus far no fatal case has been reported. 

Pityriasis Simplex. This form of scaling of the skin is 
most often seen on the scalp, where it is spoken of as pityriasis 
capitis, and constitutes that form of dandruff in which there 
is a more or less abundant scaling of the scalp. The hair is 
dry and unmanageable, and the head itches, specially when 
the patient sits under a light or becomes overheated. The 
patient is annoyed by the constant falling of the scales upon 
his clothing, and if the disease is very pronounced brush- 
ing of the hair causes a small snowstorm of white light 
scales. The scalp usually looks pale, and will be found 
covered with fine, grayish or yellowish, readily detachable 
scales. Sometimes there are more or less redness of the 
scalp and a seam of redness along the forehead. The eye- 
brows, bearded portion of the face, pubes, and other regions 
may be affected. After an indefinite time alopecia is apt to 
follow a pityriasis. This disease is usually classed under 
seborrhoea sicca. It is also claimed as a part of seborrheal 
eczema. It seems to be inflammatory in its nature. The 
treatment is the same as that for soborrhoeal eczema and for 

seborrhoea. 

18 



398 DISEASES OF THE SKIN. 

Pityriasis Tabescentium is that condition occurring in 
marasmic individuals where we have a scaling of the whole 
skin specially marked on the extensor surfaces of the ex- 
tremities and trunk. 

Pityriasis Versicolor. See Chromophytosis. 

Plaques des Fumeurs. See Leucoplakia. 

Plica Polonica (Pli'ka 3 Pol-o 2 n'i 2 -ka 3 ). Synonyms : Tri- 
chosis plica ; Trichoma ; (Pol.) Koltun ; (Grer.) Weichsel- 
zopf; (Fr.) Plique polonaise ; Polish ringworm. 

Symptoms. This is rather a condition than a disease, in 
which the hair of the head and other parts becomes matted 
together into various shaped masses, on which rest all sorts 
of extraneous matters deposited from the air ; and in which 
are harbored vast hordes of pediculi. Sometimes these 
matted tresses are near the scalp, and sometimes far away, 
according to circumstances, such as the growth of the hair 
and disease of the scalp. Not infrequently an oozing eczema 
of the scalp will be found. The masses will assume all sorts 
of shapes to which various names have been applied. An 
offensive odor often emanates from the scalp. Occurring 
among ignorant people, as is usually the case, these plicas 
are regarded with superstition. The patient and friends 
refuse to have them cut off lest some dire disease befall the 
bearer. 

Etiology. The cause of the condition is want of clean- 
liness combined with an oozing dermatitis of the scalp due 
to pediculi or any other cause. 

Treatment. The treament consists in the liberal use of 
soap and water, and curing the dermatitis. If allowed, the 
speediest way of beginning treatment is to cut off the hair. 
The patient must be instructed in the hygiene of the scalp. 

Podelcoma. See Fungous foot of India. 

Poils Accidentels. See Hypertrichosis. 

Polytrichia. See Hypertrichosis. 

Polyidrosis. See Hyperidrosis. 

Polypapilloma Tropicum. See Yaws. 



POMPHOLYX. 399 

Pompholyx (PoWfo 2 l-i 2 x). Synonyms : Dysidrosis ; 
Cheiro-pompholyx. 

This disease was first described by Tilbury Fox and Jona- 
than Hutchinson from the same case, though independently 
of each other. The former thought that it was due to dis- 
tention of the sweat glands, and named it dysidrosis, while 
the latter named it cheiro-pompholyx from the bullous char- 
acter of the eruption and its occurrence upon the hands. 
As it occurs upon the feet as „well as the hands, Hutchin- 
son's name is a misnomer. 

Symptoms. The first thing that the patient notices is a 
burning and itching of the palms, or soles, and sides of the 
fingers or toes. In a few hours small, clear, sago- grain-like 
vesicles, sometimes grouped, and with an erythematous zone 
about them, appear in these locations. They are often very 
numerous, and some of them run together to form small and 
large bullae. Their contents are at first neutral ; later they 
become turbid and have an alkaline reaction. These vesi- 
cles do not tend to spontaneous rupture. In a few days 
they dry up, their covers fall, and large and small, dry, red 
surfaces are left to mark their locations. If the lesions have 
been very numerous, the whole of the old skin may be shed. 
In slight cases the palms or soles will be dotted over with 
irregularly shaped red spots with ragged edges. As a rule, 
the backs of the hands and feet are unaffected, though the 
rule has many exceptions. The patients are seldom in perfect 
health, and are usually nervously depressed. Hyperidrosis 
of the affected parts commonly accompanies or precedes the 
outbreak, and sometimes a lichen tropicus will be found on 
the trunk. The duration of the attack varies from a few 
days to three or four weeks, and relapses in the same or 
following years are common. Most all cases are seen in the 
summer. It is usually symmetrical, though one side may 
be affected before the other. 

Etiology. Over the causes of the disease there has been 
and still is active discussion. It seems to be in some way 
connected with the sweat glands, but whether it is a simple 
impediment to the escape of the sweat or an inflammatory 
disease is not determined. Some able pathologists ally the 



400 DISEASES OF THE SKIN. 

disease to herpes. The occurrence of the disease in hot 
weather points to the sweat-apparatus as the organ at fault. 
There is probably a vasomotor neurosis at the bottom of the 
trouble. It affects all ages and both sexes, though most 
common in young adult women, and in those who are of 
nervous temperament, or the subjects of worry and over- 
fatigue. 

Pathology. Robinson, who has carefully studied this 
disease, regards it as a neurosis allied to herpes and pem- 
phigus. He thinks that it has nothing to do with the sweat 
glands, but that it is inflammatory. The contents of the 
vesicles, he shows, is not sweat, but serum, and the reac- 
tion of the fluid is alkaline or neutral in its early stages, 
never acid. It also contains a large amount of albumin 
and some fibrine. It comes from the papillary bloodvessels, 
and passing between the rete-cells collects in different situ- 
ations in the stratum mucosum. 

Diagnosis. Pompholyx must be differentiated from 
eczema, scabies, pemphigus, and erythema bullosum. It 
differs from eczema in its vesicles not tending to break 
down of themselves ; in not presenting a moist surface after 
the vesicle-tops fall ; and in running a more definite course. 
The sago-grain-like appearance of the vesicles is not pecu- 
liar to it, as it is frequently seen in eczema of the hands, 
and is due to the thickness of the epithelium preventing the 
ready escape of the fluid. Scabies may bear a close resem- 
blance to pompholyx, but can be readily differentiated by 
finding the burrows, and by the presence of the eruption at 
the same time upon the anterior face of the wrists, the breasts 
in women, the genitals in males, and about the umbilicus in 
both sexes. Pemphigus of the hands and feet is exceed- 
ingly rare in adults, and pompholyx has never been reported 
in infants. Moreover, pemphigus lacks the vesicular lesions 
of the sides of the fingers. Erythema bullosum is always 
on the backs of the hands, and is not itchy though it may 
burn. 

Treatment. A simple astringent ointment, as of oxide 
of zinc, or diachylon ; or one of the oleate of zinc or lead ; 
or an alkaline lotion, will allav the irritation and hasten the 



POROKERATOSIS. 401 

disappearance of the disease. General hygiene should be 
enforced ; and tonics of iron, arsenic, or whatever seems in- 
dicated by the condition of the patient, given. 

Porcellanfriessel. See Urticaria. 

Porcupine Disease. See Ichthyosis. 

Porrigo Contagiosa. See Impetigo contagiosa. 

Porrigo Decalvans. See Alopecia areata. 

Porrigo Favosa. See Favus. 

Porrigo Furfurans. See Trichophytosis capitis. 

Porrigo Granule. See Pediculosis. 

Porrigo Larvalis. See Impetigo. 

Porrigo Lupinosa. See Favus. 

Porokeratosis (Por-o-ke 2 r-a 2 t-o r -si 2 s). Under this name 
Mibelli, 1 and later Respighi, 2 have reported a disease of the 
skin that occurs in the form of raised or sunken patches of 
various sizes and irregular shape, with a continuous thin, 
horny, linearform ridge about them. The disease occurs 
on the dorsal surface of the hands and feet, the extensor 
surface of the forearm and leg, and exceptionally on their 
flexor surface. It may also occur on the face, neck, and 
scalp. There are no subjective symptoms. Some of the 
lesions may disappear spontaneously. Generally the disease 
spreads slowly so as to occupy large areas. 

Respighi describes five distinct forms : 1. Miliary and 
submiliary papules ; 2. Hempseed to lentil-size papules ; 3. 
Guttate to nummular papules ; 4. Ring and circinate disks, 
which is the most common form. Their edges are raised, 
regular, toothed, or zig-zag, and may be composed of pap- 
ules arranged in chains. The disks may be round, oval, or 
elliptic ; 5. Ball or muscle-shaped lesions, 3 to 4 mm. high. 
All forms begin as papules. The disease is bilateral and 
tends to symmetry. The nails may be affected, becoming 

1 Monatshft. f. prkt. Dermat., 1893, xvii. 417. 

2 Ibid., 1894, xviii. 70. 



402 



DISEASES OF THE SKIN. 



cloudy, striped longitudinally, rough, thickened, raised from 
their bed, brittle, and perhaps they may be shed. 

The disease usually begins in early childhood. Most of 
the cases are in women. Many members of the same 



Fig. 47. 




Porokeratosis ( R es pig h i) . 



family may be affected. It consists in a hyperkeratosis of 
the glandular orifices, and destroys both the glands and hair 
follicles. It is thought by Mibelli to be a species of nsevus 
unius lateris. 

Port-wine Mark. See Naevus. 

Post-mortem Warts. See Tuberculosis verrucosa cutis. 

Prairie Itch. This disease has been found to be in most 



PRURIGO. 403 

cases a combination of pruritus hiemalis and scabies. It is 
not a disease sui generis. 

Prickly Heat. See Miliaria. 

Prurigo (Pru-ri'go). Synonyms : Strophulus prurigi- 
neux ; Scrofulide boutonneuse benigne; (Ger.) Juckblat- 
tern. 

A chronic disease of the skin characterized by beginning 
in infancy as an urticaria, and changing into a recurring 
eruption of pale, hard, exceedingly itchy, discrete papules, 
especially upon the extensor surfaces of the extremities. It 
increases in severity from above downward, and is accom- 
panied by enlargement of the inguinal glands. 

There are two types of this disease, namely : prurigo 
mitis and prurigo ferox. These two blend into each other. 
While the malady is more commonly reported from Vienna 
than elsewhere, it occurs in many countries. It is rare in 
this country. The name is used by most French writers as 
synonymous with pruritus, and English writers quite com- 
monly speak of " pruriginous " diseases when confusion 
would be avoided by using the adjective " pruritic." 

Symptoms. The disease begins in infancy, quite com- 
monly toward the end of the first year, as an outbreak of 
urticarial wheals of various sizes and shapes. The urtica- 
rial eruption persists, but after a time a preponderance of 
small wheals will be remarked, and a preference for the 
trunk and the extensor surfaces of the limbs. During the 
second or third year the urticarial element is lost and the 
characteristic papular eruption gradually preponderates, and 
at last takes its place. The papules are pin-head to hemp- 
seed in size, flat, firm, of the color of the skin, or of a 
bright-red, rosy, or yellowish-white color, and in many 
cases so little raised as to be felt rather than seen. When 
the skin is irritated the papules may assume the character 
of small wheals. The efflorescence is located principally 
upon the extensor surfaces of the limbs, and more sparsely 
on the trunk, while the scalp, the flexures of the large 
joints, the palms, soles, and genitals are free. The papules 
are not grouped. 



404 DISEASES OF THE SKIN. 

Pruritus is intense, so that excoriations and torn papules 
are present over all the affected parts. The patients have a 
pale, weary expression of countenance, and evidently are in 
poor condition. The skin is often dry and it may be scaly. 

When the lesions are but few in number and scattered 
about upon the extremities, we have prurigo mitis. When 
a great number of papules are present, and the disease is 
widespread, we have prurigo ferox. Now we have the 
typical form of the disease such as is shown in the Vienna 
skin clinics. We note that the skin feels rough ; that it is 
strewn over with a great number of small papules which are 
of the color of the skin or pale- red; defaced with scratch- 
marks ; eczematous in places ; darkly pigmented, it may be 
brown, from constant irritation of the scratching, and that 
the color of the general integument is in strong contrast 
with the pale color of the face ; that the skin is thickened 
in some places while the flexures of the joints are free from 
change and as soft as normal ; that these changes in the 
skin are progressively worse from above downward, so that 
the legs from the knees down are most markedly involved ; 
and that the inguinal glands are enlarged so as to form 
buboes. Ecthymatous lesions may arise. The intensity of 
the itching may be so great as to prevent sleep, and even 
in some cases to drive the patient insane. 

The duration of the disease is indefinite ; it may last a 
lifetime, but often tends to disappear with advancing years. 
The type of the disease remains the same throughout — that 
is, prurigo mitis does not change to prurigo ferox. 

Etiology. Prurigo affects both sexes, though it is more 
prevalent in the male sex. It is far more common among the 
poor and those who are uncleanly. It is not uncommon to 
find several members of the same family with the disease. 
A phthisical family history has been affirmed to be an etio- 
logical factor by some authorities. Some cases are better in 
winter and some in summer. It is a disease of infancy con- 
tinuing through life. A neurosis probably is the underly- 
ing cause of the phenomena, and it seems to be related to 
urticaria. Histological studies have not yet put the disease 
upon a sure anatomical basis. 



• PRURIGO. 405 

Diagnosis. The diagnosis is made by the occurrence of 
pale papules upon the extensor aspects of the limbs ; by the 
increasing severity of the symptoms from above downward ; 
by the enlargement of the inguinal glands, by the peculiar 
look and complexion of the patient, and by the continuance 
of the disease from early infancy. It is to be differentiated 
from eczema by sparing the flexures of the joints ; by the 
presence of its characteristic papules, and by its greater 
obstinacy. From papular urticaria it can be distinguished 
only by its general course. In fact, a doubtful case must be 
carefully studied over a considerable length of time before a 
positive diagnosis can be made. Scabies and pediculosis 
can be readily separated by the occurrence of the lesions on 
the palms, between the fingers, and on the genitals in the 
one ; and the parallel scratch-marks over the shoulders in 
the other. Ichthyosis spares the flexures as does prurigo, 
but it is marked by polygonal scales, not papules ; and is 
free from the great number of excoriations found in prurigo ; 
it is, moreover, a disease that affects the whole body-surface 
more generally. 

Treatment. The disease is exceedingly obstinate to 
treatment. The patient must be put in as good a physical 
condition as possible by means of hygiene, cod-liver oil, iron, 
and good diet. Tincture of cannabis indica is commended 
by Crocker for relief of the itching in doses of ten minims 
increased to thirty minims to a ten-year-old child, given 
three times a day directly after meals, and intermitted for 
two weeks after every six weeks. Simon 1 and others rec- 
ommend pilocarpine hypodermically, fifteen minims of a 
2 per cent, solution once a day, for adults, or a correspond- 
ing quantity of jaborandi by the mouth. After the dose the 
patient is to be put in bed and covered with woollen blankets, 
where he is allowed to sweat for two or three hours. Carbolic 
acid, fifteen to twenty grains a day in pill, and the bromide 
of potassium, have their advocates. Antipyrine and phen- 
acetine exert a controlling influence over pruritus, and they 
are among the most valuable internal remedies in prurigo. 

1 Berlin. klin.Wochenschr., 1879, xvi. 721. 
18* 



406 DISEASES OF THE SKIN. 

The latter, though not so active as the former, should be 
tried first in full doses, as it is much safer. 

External treatment is very important. Naphthol is 
most highly commended, a 2 to 5 per cent, solution, accord- 
ing to age, being rubbed in every night, and a bath of 
naphthol-sulphur soap being taken every second night. In 
older children and adults the soap treatment of Hebra, as 
described in the section on Eczema, is useful. Sulphur oint- 
ment used as in scabies after a daily bath ; tar used as in 
psoriasis ; a 5 or 10 per cent, lotion of carbolic or salicylic 
acid, or the same combined with vaseline ; a 5 per cent, 
boric acid ointment, all have their advocates, and all may 
be tried in obstinate cases. Baths followed by inunctions 
of cod-liver oil, simple oil, tar oil, or lard, are often useful ; 
as well as baths of alum, soda, and corrosive sublimate. 
Jacquet and Tenneson report great amelioration from wrap- 
ping the affected parts in some protective dressing, such as 
rubber sheeting or absorbent cotton. The spinal douche 
might do good in some cases. Treatment should be con- 
tinued for weeks or months after apparent cure of the dis- 
ease. 

The prognosis as to cure is bad, excepting in recent and 
not severe cases. These may be cured, but, as a rule, all 
we can do is to mitigate the patient's discomfort. Relapses 
are the rule. 

Pruritus Cutaneus (Pru-ri'-tuV). Itching of the skin is 
a symptom common to a great variety of dermatoses. In- 
deed, it has been said that skin diseases might be classified 
under two divisions ; those that itch and those that don't 
itch. Eczema, scabies, urticaria, prurigo, pediculosis, are 
all eminently pruritic, but do not concern us here. 

Symptoms. By pruritus cutaneus we mean a functional 
neurosis of the skin whose only essential symptom is itch- 
ing. This induces scratching, and scratch-marks are always 
to be found as a secondary symptom. These usually are in 
the form of scratched papules. If the itching is great and 
continuous, we will have other secondary effects, such as 
thickening and pigmentation of the skin, and eczema of 
various degrees. 



PRURITUS CUTANEUS. 407 

The itching varies greatly in degree from simply an 
occasional slight attack to such an intense degree as to 
render the patient's life unendurable and tempt to suicide. 
The pruritus is commonly paroxysmal, but in some cases 
the pauses between the paroxysms are so short that the itch- 
ing is practically continuous. It is almost always worse at 
night. Changes of temperature aggravate the itching, as 
a rule. Very commonly warmth makes matters worse, and 
the sufferer will begin to scratch and keep on scratching 
while in the neighborhood of a fire, or in bed warmly 
covered. He cannot resist the impulse to scratch, and so 
in bad cases he shuns society and becomes morbid. 

Under the general title of pruritus are often placed vari- 
ous paresthesia, such as formication, tingling, and burning. 

The pruritus may be general or local. Thus we have 
pruritus universalis, a term that is rarely to be applied 
with strict accuracy, as it is seldom universal, and only 
general. In these cases the itching is now one place and now 
another. Bulkley, 1 by a series of observations on himself, 
strove to establish some law of reflex excitation, in which 
he was so far successful as to find that if he scratched one 
spot that itched, he relieved the sensation there, only to have 
it break out elsewhere. This general pruritus is most often 
encountered in pruritus senilis, or the itching of the skin 
of old people, and in pruritus hiemalis and pruritus aesti- 
valis which are induced respectively by the cold of winter 
or the heat of summer. These very often manifest them- 
selves on the thighs and legs only. 

Of local pruritus we have many instances. Thus we 
have pruritus ani which afflicts both sexes and in which the 
itching extends to the mucous membrane of the anus. 
This same extension is also seen in pruritus vulvae. This 
localized itching, with the corresponding pruritus scroti in 
men, often occurs in connection with pruritus ani. In all 
these three the parts almost always become thickened and 
eczematous from the constant rubbing and scratching to 
which they are subjected, and nymphomania is sometimes a 

1 Journ. Cutan. and Gen.-urin. Dis. , 1887, v. 459. 



408 DISEASES OF THE SKIN 

consequence of the itching vulva. The scalp, face, espe- 
cially about the nose and mouth ; the palms and soles, and 
between the fingers and toes, are frequent sites of itching. 
More rarely local areas anywhere will be affected with re- 
curring attacks of itching. 

Etiology. That the pruritus is due to a functional dis- 
turbance of the sensory nerves there is no doubt. For suc- 
cess in treatment and accuracy in prognosis it is necessary 
for us to endeavor to determine the cause of such disturb- 
ance. Hepatic derangements cause a certain proportion of 
cases. The intense itching of the skin in jaundice is evi- 
dence of this. Digestive disorders and constipation ; excre- 
tory disorders, as of the kidneys and skin ; albuminuria ; 
lithaemia ; and diabetes, all have influence in causing pruri- 
tus. Depressed mental states, and the disorders of the ner- 
vous system induced by the abuse of tobacco, tea, alcohol, 
opium, and the like, produce pruritus. Reflex influences 
from the sexual sphere, and the power of imagination, are 
responsible for some cases. In illustration of the latter 
everyone knows how many people will begin to scratch 
when the subject of lice is mentioned ; and how that long 
after the acarus is killed in scabies the patient will continue 
to complain of itching, and will not be assured that he is 
cured of his disease. 

In pruritus senilis the skin will be found to be atrophied 
and the fatty tissue underlying it absorbed, in not a few 
cases. Pruritus ani is often due to haemorrhoids or fissures 
of the mucous membrane ; or to ascarides ; or to the exces- 
sive use of tobacco. Stricture of the urethra has been found 
to be the cause of both it and pruritus scroti. Pruritus 
vulvae is very often due to pregnancy or tumors of the 
uterus or ovaries. In this form diabetes is quite commonly 
the cause. Pruritus hiemalis begins at any time from Oc- 
tober to January, and continues until the spring is well 
advanced. The effect of cold upon the skin seems to check 
the secretory functions. 

Bulkley has found pruritus to be more common in men 
than women, fifty of his eighty cases being men. In some 
families an itching skin seems to be hereditary. 



PRURITUS CUTANEUS. 409 

Diagnosis. If we bear in mind that pruritus has no 
lesion of its own ; and if, whenever a patient complains of 
itching of the skin, we institute a search for the pediculus, 
or the itch-mite, or their lesions ; or the wheal, or at least a 
history of it ; and find none, then we have gone far toward 
establishing a diagnosis of pruritus. Sometimes it is diffi- 
cult to determine whether an eczema is secondary to the 
scratching for the relief of itching, or the itching is a part 
of the eczema. Only an attempt at curing the eczema and 
long observation of the case will enable us to make a true 
diagnosis. Many errors of diagnosis will be changed by 
close study, as true pruritus is not so common as other itch- 
ing diseases. Bulkley found but eighty cases in 5000 pri- 
vate cases. 

Treatment. To find and remove the cause is the first 
essential in treating a case. How difficult this task may be 
will be seen by a study of its etiology. Nevertheless the 
patient must be considered, and every organ interrogated, 
and any deranged function regulated as far as possible. 
Tea, coffee, and tobacco should be interdicted ; a dietary 
carefully laid down ; and the rules of hygiene, such as those 
relating to exercise, bathing, and clothing, enforced. To 
relieve the itching as such, we may give the tincture of 
cannabis indica, 10 minims three times a day, in water after 
meals, and gradually increase the dose up to 20 or 30 
minims ; or the tincture of gelsemium in 10-minim doses 
every half-hour till one drachm is taken or toxic effects pro- 
duced ; hypodermatic injections of pilocarpine, j 1 ^- to ^ of 
a grain ; quinine, 10 to 15 grains at bedtime ; carbolic acid, 
1 to 2 minims three times a day ; wine of antimony, 5 to 7 
drops after meals ; salicylate of soda, 15 grains, or anti- 
pyrin or phenacetine in full doses. Besnier recommends 
valerian, or valerianate of ammonia. But the relief so ob- 
tained is transitory, and we should not rest content until 
we have found out, and where possible removed, the internal 
underlying cause. Opium should never be given, as it 
causes pruritus. 

The external treatment is of great service in alleviating 
the itching, even if it does not cure the disease. For this 



410 DISEASES OF THE SKIN. 

purpose general baths with soda (Sviij-x to 30 gallons), or 
nitric or hydrochloric acid (§j to 30 gallons), may be used. 
After the bath the body is to be dried by wrapping in a 
warmed sheet and patting the skin dry ; then the skin 
should be smeared with vaseline and powdered with corn- 
starch from a flour-dredger. For local pruritus we may 
use lotions, of which one of the most efficient is carbolic 
acid. 

&. Acid carbol., 3J~ij- 

Liq. potassse, ^j. 

01. lini , §j. 

Sig. Shake before using (Bronson). M. 

The patient should be cautioned to tap the skin gently 
with this, and not rub it in. So used it will cause no dam- 
age and will stop the itching for hours. It may be used as 
a spray in the strength of half an ounce to the pint of water 
with one ounce of glycerin. To this 5 to 20 minims of 
oil of peppermint may be added (Hardaway). Alkaline 
lotions, as bicarbonate of soda, 5j to the basinful of water ; 
or acid lotions, such as vinegar dabbed on the itching spot, 
will often relieve. Liquor carbonis detergens, 3j to Siv ; 
thymol, 5ij ; liquor potassii, 5j ; glycerin, 3iij ; aquae, §viij 
(Crocker). Liquor picis alkalinus, 3j to §iv ; perchloride 
of mercury, gr. J-3 to §j of water. All these are well 
attested as useful. Peroxide of hydrogen is highly com- 
mended by Bronson. It may be used as a toilet wash two 
or three times a day. 

For pruritus ani, scroti, et vulvae, sitting over a basin 
or pail of very hot water and sopping it up on the parts, 
followed by patting the skin dry and using a starch powder, 
will often give the patient a quiet night. If an eczema is 
present, that must first be cured. Cocaine lotions, as one of 
20 per cent, of cocaine and 5 per cent, of glycerin ; or men- 
thol 3 to 10 per cent, in oil of sweet almonds, or of glycerin 
and water ; carbolic acid lotions are also useful, as well as 
manv mercurial ointments. Cocaine had best be left alone, 
as there is always danger of forming the cocaine-habit from 
the use of this seductive drug. Bulkley's antipruritic 
powder, of one drachm each of camphor and chloral, rubbed 



PSEUDO LEUCMMIA CUTIS. 4H 

together till liquefied, and added to one ounce of starch 
powder, will sometimes prove very effective. Painting the 
parts with nitrate of silver, 16 grains in spts. setheris 
nitrosi §j, is another good proceeding. A saturated solu- 
tion of boric acid is also good. When the parts are excori- 
ated neither menthol, peppermint, nor the chloral-camphor 
powder can be used. Suppositories containing belladonna, 
cocaine, or creasote may give relief in these cases. Of 
course hemorrhoids, fissures, or other rectal diseases must 
be cured if found. 

In pruritus hiemalis it is sometimes necessary for the 
patient to wear linen underclothing next to the skin ; and 
over these the woollens usually worn. Other patients find 
more relief from wearing silk underclothing. The treatment 
indicated above for pruritus is applicable here also. 

In some obstinate cases of general pruritus great amelio- 
ration may be obtained by the actual or Paquelin cautery 
applied lightly along the spine. The same means has some- 
times been successful in localized pruritus, as of the vulva 
or scrotum, but now the parts themselves are touched with 
the cautery. Spinal douches are highly thought of by some 
French authorities. 

Prognosis. The prognosis is doubtful. Some cases 
are very obstinate, and some are incurable. Happily, 
thorough study of the case will be rewarded in most cases 
by a cure. 

Pruritus Hiemalis. See Pruritus cutaneus, 

Pseudo Exantheme Erythemato-desquamatif. See Pity- 
riasis rosea. 

Pseudo Erysipelas. By this term is meant cellulitis or 
diffused phlegmon. 

Pseudo Leucaemia Cutis is a very rare disease. A case 
is reported by Joseph 1 as occurring in a man of previous 
good health. It commenced as a number of small glandu- 
lar swellings in the neck. Shortly after their appearance 

1 Deutsche med. Wochenschrift, 1889, p. 946. 



412 DISEASES OF THE SKIN. 

severe general pruritus began to afflict the patient. Then 
the inguinal and axillary glands became greatly enlarged, 
and a general eruption of hempseed-sized papules occurred. 
These were more easily felt than seen, and were of pale-red 
color. The epidermis over them was unchanged. Wheals 
also appeared that changed into papules. The skin be- 
tween the papules was dark-colored, thickened, and dry. 
The case ran a chronic course, marked by relapses. 

Psora. See Psoriasis. 

Psoriasis (So-ri 2 -a'-si 2 s). Synonyms : Lepra ; Lepra 
alphos ; Alphos ; Psora ; (Grer.) Schuppenflechte. 

A disease of the skin characterized by an eruption of 
round or oval, bright-red patches covered with more or less 
thick, silvery-white, adherent scales ; by occurring espe- 
cially upon the extensor surfaces of the elbows, knees, and 
extremities, and upon the scalp ; by running a chronic 
course marked by remissions and relapses ; and by being 
more or less pruritic. 

This is one of the more common skin diseases, forming in 
this country about 3 per cent, of all cases. 

Symptoms. Its features of variously sized, sharply de- 
fined red papules or patches covered with more or less 
abundant silvery-white scales that occur specially upon the 
extensor surfaces of the elbows and knees, are so pronounced 
that the disease once seen is readily recognized even by the 
tyro. 

The primary lesion of psoriasis is always a rather bright- 
red, pin-head-sized papule covered with a dry silvery-white or 
grayish scale. It is rare to meet with a case in which 
these small lesions are seen alone, and when it is, it is called 
psoriasis punctata. Careful search of any but an inveterate 
case will be rewarded by finding these lesions somewhere on 
the body. They soon begin to enlarge by peripheral exten- 
sion into larger patches which have received various names, 
although all the same disease. When they attain the 
diameter of about one-quarter of an inch, and bear a rather 
thick scale, they look like drops of mortar, and the case is 
then spoken of as psoriasis guttata. When the lesions 



PSORIASIS. 



413 



form coin-sized patches we speak of psoriasis nummularis. 
A single patch may grow to be two inches in diameter, or 
even larger, and preserve its circular shape. But the large 
patches are usually formed by the coalescence of several 
smaller patches, and may attain to a size sufficient to cover 



Fig. 48. 




Psoriasis. (From Prof. G. H. Fox's service at the Vanderbilt clinic.) 



the greater part of a limb, or even the trunk. Its circular 
outline is now lost, and the patch has a more or less scal- 
loped, indented border bearing so strong a resemblance to 
the maps drawn by children, that Piffard suggested the 
term psoriasis geographica for it ; but the more usual name 



414 



DISEASES OF THE SKIN. 



is psoriasis diffusa. After a patch has reached a certain size 
it may clear up in the center and form a ring, and in this 
way we have psoriasis cireinata. Several of these rings may 
meet at their circumference, when the points of contact will 
disappear and gyrate figures will be formed. When the 



Fig. 49. 






Psoriasis. (From Prof. G. H. Fox's service at the Vanderbilt clinic.) 

eruption is so general as to involve the whole or the greater 
part of the body, we speak of it as psoriasis universalis. 
Not infrequently these cases bear a striking resemblance to 
dermatitis exfoliativa. 

Every case of psoriasis does not exhibit all these varieties, 



PS0BIAS1S. 415 

because the disease may stop short at any period of its evo- 
lution. But in any case there is apt to be a number of 
variously sized lesions. Whatever the size of the patch may 
be, it will always be observed that the redness extends a little 
bevond the scales. The amount of the scaling will vary. 
Sometimes the scaling will be but slight ; sometimes it will 
be so abundant that it will heap up into such crust-like 
masses as to suggest the adjective rupioide. The scales are 
constantly being shed, and as constantly renewed. They 
may be readily scraped off with the nail, and if this is care- 
fully done a delicate glistening membrane will be exposed, 
under which will appear dot-like red points. That is, we 
have removed the epidermis and exposed the mucous layer 
of the skin, the red points being the tops of the slings of 
bloodvessels of the papillae. This is thought by some to be 
a characteristic of psoriasis, but with care it may be produced 
in other diseases. 

[The color of the scales is silvery -white or grayish. 
Darker scales are due either to the deposition of dust, or 
the admixture of blood. The color of the patch will vary 
from a pinkish-red to a dark red, the darker color being 
seen upon the legs, where the color of all lesions is darker 
on account of the partial stasis in the flow of blood. The 
disease is always a dry one, there being absolutely no dis- 
charge feature in its course. The patches are sharply de- 
fined, but so little raised that they can be nearly all scratched 
away. 

While psoriasis may occur anywhere on the body, and, as 
we have seen, may become universal, its most frequent loca- 
tions are the extensor surfaces of the limbs, elbows, and 
knees, or rather the face of the tibiae just below the knee, 
and the scalp. It may occur upon the first two locations 
alone. When it occurs on the scalp careful examination 
will show some lesion elsewhere on the body, and we will 
usually find a little patch in front of the ears, and very often 
there will be a red scaly line on the forehead just in front 
of the hair-line, a feature that is as striking and as charac- 
teristic of psoriasis as the corona veneris is of syphilis. The 
hair does not fall, as a rule. In some cases, however, we 



416 DISEASES OF THE SKIN. 

may have transient or permanent alopecia. The whole scalp 
may be covered with a continuous patch, or distinct scaly 
patches may form as on the body. In any event the border 
of the patch will be sharply defined. 

The palms and soles are very rarely the seat of the dis- 
ease, and then only as part of general psoriasis. It is true 
that a few cases have been reported in which it has been 
said even to be located upon one hand alone, and this by 
competent observers ; but the probabilities are all in favor 
of such cases having been either syphilis, which is most 
likely, or squamous eczema. The disease is bilateral and 
sometimes may show a decided tendency to symmetry. 

In old inveterate cases there may be considerable thicken- 
ing of the skin, a feature that is usually wanting, and fissures 
may form about the joints that may be painful and bleed. 
This may also occur on the scrotum, or the trunk where 
the skin is in folds. 

The nails are affected in some cases, becoming opaque, 
lustreless, furrowed transversely, discolored, and sometimes 
cracked ; while they are raised from their beds by the ac- 
cumulation of scales underneath them. All the nails are 
rarely diseased at the same time ; usually it is but one or 
two nails on each hand or foot. Sometimes the disease is 
limited to a strip along the side of one nail. 

There is no constitutional disturbance in this disease, the 
patients usually being in as perfect health as the majority 
of mankind. Sometimes they will have pains in the joints 
that are regarded as rheumatic by some, and as neurotic by 
others. Itching is very often an annoying symptom. Some- 
times it is entirely wanting. 

The course of the disease is variable. Although it is always 
chronic, it presents at times acute symptoms. Relapses are 
the rule to which there are few exceptions. In some cases 
the skin will be entirely free from all trace of the disease for 
months or years. In most cases this freedom is only par- 
tial ; even though the patient thinks he is clean, some little 
spot will be discoverable. The duration of each patch is 
also variable. It may disappear in a few weeks or remain 
for months. Most cases are better in summer, to become 



PSORIASIS. 417 

worse in winter. When the patches disappear they do so 
completely, though a slight amount of scaling may be pres- 
ent for a short time. In a few very rare cases a chronic 
psoriatic patch has become papillomatous, and then epithelio- 
matous. 

Etiology. Various theories have been advanced in the 
etiology of psoriasis, and some facts have been established 
by our study. We know that the disease is hereditary in a 
number of cases. Greenough 1 found the proportion as high 
as one-third. It may occur at any age. Kaposi has re- 
ported a case at eight months of age, and Riehl 2 one at 
thirty-eight days. It usually is a disease of early adult 
life, making its first appearance before the thirtieth year. 
It is rare after the fiftieth year. It affects both sexes, and 
all conditions of life. These things we know. 

While the majority of patients seem to be in the best of 
health, some are rheumatic or gouty. A lowered condition 
of the general health seems, in some cases, to favor an out- 
break either of a primary attack or of a relapse. Thus it is 
no uncommon thing to see the disease in women grow worse 
during pregnancy or lactation. Mal-assimilation or diges- 
tive disorders also seem to aggravate or provoke the disease, 
Hardaway even affirming that he has known the inordinate 
eating of oatmeal to cause the disease, while Gowers 3 reports 
cases produced by the ingestion of borax as a medicine. 
Polotebnoff 4 has written an elaborate thesis to show that the 
disease is a vasomotor neurosis, affirming that in a majority 
of cases there will be found evidences of either trophic or 
vasomotor disturbances, or a history of more or less profound 
nervous troubles either in the patient or his family. A 
number of cases following fright or nerve-shock have been 
reported. In the Vierteljahressclirift f. Dermat. u. Syph. 
for 1878, Lang brought out his parasitic theory, and in No. 
208 of Volkmann's Sammlung klinisclie Vortraye the thesis 
is further elaborated, the fungus being represented by illus- 

1 Boston Med. and Surg. Journ., 1885, cxiii. 163. 

2 Monatshft. f. prkt, Dermat. , 1895, xxi. 283. 

3 Lancet, October 24, 1884. 

* Monatshefte f. prakt. Dermat., 1891, Erganzungsheft jSo. 1. 



418 DISEASES OF THE SKIN. 

trations. He has found some support from other observers, 
but the theory has not gained general credence. 

It is a well-known fact that an injury to the skin of a 
psoriatic, such as a pin-scratch, will determine the location 
of a patch of psoriasis. 

Pathology. Pathologists by no means agree in their 
teachings as to the histology of psoriasis. By some it is 
regarded as inflammatory, while others believe it to be a 
keratolysis, or an anomaly of cornification in which an im- 
perfect corneous layer is formed. Some teach that the pro- 
cess begins in the rete, and the changes in the corium are 
secondary ; while others holds the reverse view. Lang 
names his parasite epidermidophyton, and describes it as 
composed of mycelia and spores, either disseminated or in 
groups, which are so delicate as to be found only with very 
high powers. 

Diagnosis. A typical case of psoriasis presenting round 
or oval, variously sized, red, dry patches covered with thick 
silvery-white scales, scattered more or less generally over 
the body, but showing a marked preference for the extensor 
surfaces of the extremities and especially of the elbows and 
knees, is readily recognized. In some less typical cases it 
needs to be differentiated from syphilis, eczema, seborrhoea, 
dermatitis exfoliativa, lichen ruber, and lichen planus, 
Unna's seborrhoea! eczema, and possibly from lupus erythe- 
matosus. From the squamous syphilide of the secondary 
stage of the disease it differs by showing preference for the 
extensor surfaces of the limbs and the posterior surface of 
the trunk, though there are many exceptions to this rule. 
The syphilide is not so scaly ; its red is darker, more raw- 
ham-colored ; the lesions are more infiltrated, giving a more 
shotty feeling to the finger ; they do not itch ; they run a 
more acute course, and are of more uniform size, never ex- 
hibiting the patchy character of psoriasis. It is usually 
easy to establish the presence of other manifestations of 
syphilis, such as sore-throat, pains in the bones, fall of the 
hair, and perhaps the remains of the initial lesion. The 
late scaly syphilide is never general; is unsymmetrical, 
usually consisting of one or two groups of lesions that show 



PSORIASIS. 419 

no tendency to affect the elbows and knees. The lesions 
are more raised and prone to leave scars. There will also 
be the history of past syphilides to guide us, and an absence 
of those relapses so common and characteristic of psoriasis. 

Eczema squamosum is far more pruritic than psoriasis 
usually is ; the patch is more infiltrated ; the scaling is less, 
the scales being thinner ; exudation can be readily induced ; 
and a history of moisture at some time will be found. The 
patch of eczema is generally less sharply defined, and is 
more apt to shade off into the surrounding skin. If the 
scales of a psoriatic patch are removed, a delicate mem- 
brane is left showing red dots — the tops of the bloodvessel 
slings in the papillae ; if the same thing is done in eczema, 
a discharging surface will be left. 

Seborrhea may simulate a psoriasis when it occurs in 
patches on the chest, or as thick crusts on the scalp. The 
patches on the chest have a more yellow color and their 
scales a more greasy feel than is the case in psoriasis. On 
the scalp the crusting of seborrhoea does not occur in such 
sharply defined patches, and its crusts are very greasy. 
In either case, if it be one of psoriasis, we will be sure to 
find one or more typical lesions somewhere on the trunk. 

It is quite impossible to differentiate a true case of derma- 
titis exfoliativa at first sight from one of general psoriasis. 
If it does arise from psoriasis, there will be a history of its 
gradual spread from typical lesions quite different from 
what obtains in true dermatitis exfoliativa, which is more 
rapid in its evolution. Psoriasis is rarely so absolutely 
universal as is dermatitis exfoliativa. Watching the case for 
a time will establish the diagnosis. If psoriasis is the 
malady, it will declare itself after a time by the diffused 
redness clearing up and typical psoriatic patches showing 
themselves. 

Lichen ruber presents small pointed papules upon the 
trunk at first, and not the large, scaling papules upon 
the extensor surfaces of the limbs of psoriasis. When the 
disease becomes general we will have the history of these 
lesions, and a much greater thickening of the skin. 

Lichen 'planus occurs by preference on the flexor rather 



420 DISEASES OF THE SKIN. 

than the extensor aspects of the limbs, and in the form of 
a flat, shining, angular, smooth papule, rather than a round, 
freely scaly one. The color of its patch is violaceous and 
not bright red. If it becomes universal, it does so evidently 
by the springing up of new small lesions between the old 
ones, and not by the peripheral growth and coalescence of 
those already existing. The thickening of the skin is also 
much greater than in psoriasis. 

In the diagnosis from seborrheal eczema, Unna lays 
great stress upon four points : 1. Seborrhceal eczema 
spreads from above downward, mostly in the middle line of 
the body, and its lesions are quite stationary in character ; 
while psoriasis begins on the elbows and knees, and more 
speedily affects the whole body. 2. There is always a his- 
tory of a seborrhceal affection of the scalp in seborrhoeal 
eczema. 3. The scales of seborrhoeal eczema are fatty and 
crumbling, and the patches are yellowish ; in psoriasis the 
scales are white and friable, not greasy, and the patches are 
bright red. 4. The proneness of the patches of seborrhoeal 
eczema to form bow-shaped figures, or rings more or less 
broken. Psoriasis may be circinate, but the margins of the 
figures are not so narrow and not follicular as they may be 
in seborrhoeal eczema. 

Treatment. Though external treatment alone will 
remove the evidences of psoriasis upon the skin, producing 
a cure of the disease — if that may be said of a disease that is 
almost sure to relapse — we generally can procure more 
prompt results by a combination of internal and external 
remedies. The first inquiry in all cases should be made as 
to the general condition of the patient, and we should 
endeavor to establish in him as perfect a state of health as 
is possible A restricted diet certainly does have a good 
deal of influence in causing an amelioration of the disease. 
No hard and fast lines can be set in this respect. Under my 
esteemed teacher, Prof. George Henry Fox, who is a strong 
advocate of dieting in skin diseases, I have seen some 
patients improve under a strictly vegetable diet, and others 
do equally well on a dietary composed largely of milk and 
animal food. A stout, evidently overfed, plethoric patient 



PSORIASIS. 421 

will be benefited by cutting off all, or nearly all, meat. In 
this class of patients it is a good plan to insist upon a milk 
diet for a few days. An anaemic, underfed patient will, on 
the other hand, improve under a more liberal dietary. 
Alcoholics, and especially malt liquors, should be inter- 
dicted in all cases, as well as rich gravies and highly spiced 
foods. 

Besides these general measures we have a number of 
drugs that have gained a more or less well-earned reputa- 
tion as remedies for psoriasis, though it must be confessed 
that they are more or less empirical remedies. 

Arsenic would be named, without doubt, by most general 
practitioners as the remedy for psoriasis. It does do good 
in this disease, but at the same time it is not to be con- 
sidered as a true specific. In acute cases it aggravates the 
disease and should never be given. In chronic cases that 
have proved very stubborn it may be tried, and sometimes 
it will produce a speedy cure. The vast majority of cases 
will do quite as well without it. It may be given in the 
form of Fowler's solution with or without the wine of iron, 
and administered in water three times a day after meals. 
The initial dose for an adult should be about three drops, 
and the amount should be gradually increased until the 
limit of toleration is reached. Crocker thinks that the effi- 
ciency of this form of arsenic is enhanced by the addition 
of half a drachm of the tincture of lupulus to each dose. 
The Asiatic pill is the favorite mode of using arsenic in 
Vienna. It is composed, according to Kaposi, of — 

R. Pulv. ac. arseniosi, 75 

Pulv. piperis nigree 6 

Gummi acacise, 1 50 

Pulv. althse. rad., 2 

Aquse, q. s. M. 

Div. in pil. no. c. 

One pill is given after meals, and the dose is increased 
gradually every four or five days until ten or twelve are 
taken a day, unless some constitutional disturbance is 
caused before then. The method of increase is by first 
giving one pill after each meal ; then two pills after break- 

19 



422 DISEASES OF THE SKIN. 

fast, and one after the other two meals ; and then two after 
breakfast, two after the midday meal, and one in the even- 
ing, and so on. Or we may make use of the tablet triturates 
of arsenious acid with piperina, giving those containing one- 
twentieth of a grain of the arsenic in the same manner as 
the Asiatic pills. Any other preparation of arsenic may be 
used. Hypodermatic injections of arsenic have been em- 
ployed with success, but it would be hard to induce an 
American patient to endure this method. The administra- 
tion of the drug must be persisted in for a long time, and 
it may prove curative by itself. 

Alkalies that act as diuretics are often very helpful, quite 
apart from any indication for their use on account of gout or 
rheumatism. A beginning psoriasis, or even a case of some 
duration, will be favorably influenced by the administration 
of the acetate or citrate of potassium in fifteen-grain doses 
before meals, well diluted, and followed by drinking half a 
glass of water. The undoubted efficacy of large doses of 
the iodide of potassium, as recommended by Haslund, 1 may 
depend in part, at least, upon its diuretic action. He gives 
the salt in increasing doses so that as much as 600 grains 
have been administered to one patient during the day. 
When assistant physician to the New York Skin and Can- 
cer Hospital, on Dr. Gr. H. Fox's division, I tried Haslund's 
plan in several cases. They certainly were greatly bene- 
fited. The objections to this method are the expense of the 
drug and the danger of the sudden production of poisoning, 
shown by palpitation of the heart, severe headache, and 
faintness, and necessitating either keeping the patient in a 
hospital or under the constant attendance of a physician. 

Turpentine oil is highly commended by Crocker as fol- 
lows : It may be given in capsule, or, preferably, as an 
emulsion rubbed up with mucilage of acacia. The initial 
dose is ten minims three times a day after meals. It may 
be increased by five or ten minims at a dose until the pa- 
tient, if tolerant of it, is taking thirty minims three times a 
day. Barley-water must be freely drunk during the day to 

1 Vierteljahr. f. Derm. u. Syph., 1887, xiv. 677. 



PSORIASIS. 423 

prevent any bad effect on the kidneys, and the last dose of 
the turpentine should not be taken later than six or seven 
o'clock in the evening. Dyspepsia and irritability of the 
urinary organs contraindicate its use. The same authority 
advocates the use of salicylate of soda in fifteen-grain doses 
three times a day after meals. 

The wine of antimony in five- to ten-minim doses is 
recommended by Mr. Malcolm Morris as efficacious in acute 
cases. 

Chrysarobin by the mouth, one-sixth of a grain in sugar 
of milk three times a day, and increased to one or two 
grains at a dose, acts well in some cases, but is very apt to 
cause so much nausea and vomiting as to compel its discon- 
tinuance. 

Polotebnoff advocates the use of bromide of potassium, 
believing the disease to be a neurosis, and of ergot. 

External treatment. Before making any application to 
the psoriatic skin the scales must be removed by bathing 
with soap and water, or by warm alkaline baths. Some- 
times bathing followed by inunctions of the skin with sim- 
ple oil, or vaseline, combined with attention to diet, will 
produce a cure. These measures should be tried first in all 
newly beginning cases. In some cases there will be well- 
marked eczematous conditions. Then we must use remedies 
applicable to that disease. Generally we must resort to more 
stimulating remedies. The most useful and most promptly 
curative external remedy is chrysarobin (chrysophanic acid). 
The objections to it are its tendency to produce an acute 
dermatitis and its permanent staining of everything with 
which it comes in contact. These unpleasant effects may 
be in part overcome by combining the drug with flexible col- 
lodion or traumaticin, but only in part. The dermatitis is 
always most marked upon those parts in which there is 
laxity of the skin, and if it is used on the face it is prone 
to produce great swelling about the eyes. Care must be 
taken not to get it in the eyes, as it causes violent conjunc- 
tivitis. These effects should make us very cautious about 
using it on the scalp, and prevent its use on the face. 

The most active form in which to use the drug is in an 



424 DISEASES OF THE SKIN. 

ointment as of lard, lanolin, or vaseline. Bassorin and plas- 
ment are excipients that have the merit of not being greasy, 
and of being readily and entirely removed by means of water. 
Flexible collodion or traumaticin, the liquor gutta-perchse, 
are good excipients. 

The strength of chrysarobin should not exceed one drachm 
to the ounce, as a rule, though in exceptional cases it may be 
used in greater strength. Its activity is increased by the ad- 
dition of salicylic acid (3 per cent.), and then it is best to 
use it in a lower percentage, even 5 per cent, being active 
enough. An alkaline bath before using the chrysarobin 
increases its potency. If we use an ointment, it should be 
thoroughly rubbed in once a day after the scales are re- 
moved. If our vehicle is bassorin, plasment, collodion, or 
gutta-percha solution, the spots should be painted over 
as often as the film left by the application falls. The 
patient should always be warned against getting the drug 
in his eyes. A favorite formula of Dr. George H. Fox is 
the following : 

Be. Chrysarobin, ) „ 

01. cadi, f aa Z parts - 

Ac- carbolici, 1 part. 

Ac. oleic, 50 parts. M. 

If the chrysarobin produces too great a reaction, it must 
be stopped, and the skin treated with vaseline and starch 
powder, or an alkaline wash. The action of the drug upon 
the skin is peculiar. It stains the skin about the patches 
of a mahogany-red, while the patches become smooth and 
white. It discolors the nails and the hair, but after a 
time the staining disappears. Not so the staining of the 
clothing, which is permanent. It is said that it can be 
somewhat lessened by soaking the clothes in plain water 
before using soap in washing. 

Before chrysarobin was discovered much reliance was 
placed on the ointment of the ammoniate of mercury. It is 
still a reliable remedy, but it cannot be used over the whole 
body in a general psoriasis on account of the danger of 
absorption of the mercury. It is the pleasantest and prompt- 
est application to the scalp and face, and can be used there 



PSORIASIS. 425 

while chrysarobin is used on the rest of the body. Other 
mercurial ointments, such as that of the yellow oxide, and a 
dilute ointment of the nitrate, may be used. Lang has 
found the bichloride of mercury in collodion in J to J- per 
cent, strength a good application. It would probably be an 
unsafe one in a case of any extent. 

Tar is another old and reliable remedy, still much used in 
France. It may be employed in an ointment, or oil, or dis- 
solved in alcohol. The oil of cade, oil of birch, or pure tar 
may be used in the strength of half a drachm to four 
drachms to the ounce. In Paris the following is sometimes 
used : 

Be . Glycerole of starch, ) -, AA , 

Oil of cade, } aa 10 °P arts ' 

Green soap, 5 " M. 

This is to be rubbed in at night, the patient is to sleep in 
a flannel gown, and wash the stuff off in the morning : 
Kaposi recommends the following : 

K . 01. rusci, 50 parts. 

Etherissulphuris, ) -- „ n u 

Alcoholis, / aa 75 

Filter and add 

01. lavandulse, 2 " M. 

Tar in any form is a dirty application, and is prone to 
produce inflammation of the skin, as well as toxic symp- 
toms. Pyrogallol (pyrogallic acid) is efficacious, but can 
only be used in cases in which the eruption is not extensive, 
on account of its poisonous action when absorbed. It may 
be used in the strength of about 10 per cent, in ointment. It 
stains the skin, but causes less inflammatory reaction than 
chrysarobin does. 

Thymol was introduced by Crocker. It may be used as 
an ointment or lotion in the strength of 15 grains to 3 
drachms to the ounce. As it is colorless and of pleasant 
odor it is suitable for use on the face. The same authority 
advocates the use of turpentine locally. He uses the oleum 
pini sylvestris with sufficient oil of lavender or essence of 
lemon to cover its odor. If used undiluted, the skin must 
be smeared with vaseline to prevent its cracking. It is 



426 DISEASES OF THE SKIN. 

better to use it diluted with olive oil, 5j oil of turpentine 
to 5vij of olive oil, the proportion of the oil of turpentine 
being increased as the skin becomes accustomed to it. The 
addition of oil of cade or oleum rusci to the mixture in- 
creases its efficacy. 

Salicylic acid, 5 to 20 per cent, strength, will remove the 
scales, and in some cases will prove curative. The soap 
treatment, as described in chronic eczema, is of great value 
in some chronic circumscribed cases. Sulphur ointment, 
oleate of copper, " rufigallic " acid, 10 per cent, in oint- 
ment, resorcin, have all done well in some cases. Hydrace- 
tine, anthrarobin, and aristol are among the latest remedies, 
but have not proved themselves as active as some of the 
older ones. 

Gallacetophenone in 5 to 10 per cent, strength as oint- 
ment or dissolved in collodion may be tried, but is not as 
good as chrysarobin. 

Some patients have found benefit from the use of natural 
mineral waters at spas. It is possible that much of the 
benefit so obtained is from the prolonged and regulated 
bathing. Wearing rubber clothing next the skin, or with a 
fine piece of muslin between the rubber and the skin to avoid 
the production of eczema by the rubber, will soften and 
remove the scales, and hasten the disappearance of the 
patches. 

Prognosis. A cure of psoriasis may be promised with a 
fair degree of certainty as far as the removal of the eruption 
then out is concerned. But no promise can be made that 
the disease will not relapse. In this respect proriasis resem- 
bles rheumatism and gout. While most relapses are readily 
removed in the course of a few weeks, in some cases one or 
more patches will be remarkably obstinate. 

Psorospermosis Follicularis Cutis is the name given by 
French writers, notably by Darier, 1 to a disease of the skin 
cases of which had previously been reported under the names 
of lichen spinulosum (Hutchinson), ichthyosis sebacea cornea 
(Wilson), acne sebacea cornea (Gruibout), ichthyosis folli- 

1 Ann. de Derm, et de Syph., 1889, x. 597. 



PURPURA. 427 

cularis (Lesser), keratosis follicularis (Morrow and White), 
acne" cornee (Leloir and Vidal), cacotrophia folliculorum 
(T. Fox), and sauroderma. The title psorospermosis was 
given by Darier because he believed that he had found cer- 
tain parasites belonging to the order of protozoa, which have 
been named psorosperms in causal connection with the dis- 
ease. (For description of the disease see Keratosis folli- 
cularis.) 

Pterygium (Te 2 r-i 2 j r i 2 -u 3 m) is simply an overgrowth of 
the normal nail-fold at the proximal end of the nail so that 
it covers, to a greater or less extent, the lunula. It may be 
cut off. 

Purpura (Purp'u 2 r-a 3 ). Synonyms : Hsemorrhoea pete- 
chialis; (Grer.) Blutfleckenkrankheit. 

Symptoms. By this term is meant a hemorrhage into the 
skin which is not caused by direct traumatism. It is always 
readily recognized by the red, purple, or blue-black color 
that it causes, which cannot be made to disappear by pres- 
sure. The hemorrhage may take place into any part of the 
skin ; into the subcutaneous tissues ; or into any of the 
glandular apparatus of the skin. It occurs with sudden- 
ness, and produces variously sized lesions to which certain 
names have been applied. When they are small, from pin- 
point-size to perhaps an inch in diameter, they are called 
petechice. When occurring in the form of more or less long 
streaks they are called vibices. Large bruise-like lesions 
with more or less swelling are ecchymoses. Blood tumors 
of all sizes are eccliymomata or hcematomata. The color of 
all purpuric lesions depends upon their age. When first 
formed they are bright red, claret, or purple. Before dis- 
appearing they pass through various shades of color such as 
are seen after an ordinary bruise, becoming blue-black, 
greenish-black, or brownish. These changes are due to 
the gradual absorption of the effused blood and the hsematin 
deposited from the blood globules. There is no definite 
time for complete absorption to take place, but eventually 
no trace is left of the previous hemorrhage. 

If the extravasation of blood takes place into the hair fol- 



428 DISEASES OF THE SKIN. 

licles, we will have papules formed. If between the layers 
of the epidermis, hemorrhagic bullae may result. Hemor- 
rhage into sweat glands will give rise to haematidrosis. As 
complications of other dermatoses hemorrhage may occur, as 
in urticaria, pemphigus, and eruptive fevers, but these should 
not be elevated into special varieties of purpura. 

There are three varieties of purpura, namely, purpura 
simplex, purpura hemorrhagica, and purpura rheumatica. 
It is convenient for us to preserve these varieties for a time, 
though the results of the latest studies seem to indicate that 
the second variety is but a more developed form of the first, 
cases of simple purpura having been seen to run into the 
hemorrhagic form. By Crocker and others the third variety 
is regarded as a form of erythema exudativum. It, too, has 
been seen to run into the hemorrhagic form. 

Purpura Simplex is the most common variety, and usu- 
ally takes the form of petechia?, the lesions being round or 
oval, or irregular in shape, or even circinate. Duhring de- 
scribes a case of the circinate form, as does Stel wagon. 1 The 
lesions appear suddenly, generally without antecedent symp- 
toms, and often at night. Like other varieties of purpura, the 
lower extremities are the most common seat of the eruption, 
especially their flexor aspects, but any part of the skin may 
be attacked, as also the mucous membranes. Crocker affirms 
that in children the lesions appear first upon the neck and 
upper part of the back. The lesions appear in crops, and 
most often are symmetrical. There may be but a single 
outbreak, and the whole disease may be at an end in a week 
or two. But it may be prolonged for many weeks by a 
succession of outbreaks. There is usually no constitutional 
disturbance, and the only things the patient complains of 
are the spots, and perhaps some itching. There may be 
lassitude, malaise, and slight elevation of temperature. Re- 
covery is the rule. Exceptionally purpura simplex passes 
over into 

Purpura Hcemorrhagica. This form is also called mor- 
bus maculosus Werlhoffii and land scurvy. It usually 

1 Journ. Cutan. and Gen.-urin. Dis., October, 1887. 



PURPURA. 429 

begins as such, and is heralded by pronounced malaise, 
headache, and perhaps convulsions. It begins without pro- 
dromata. It differs from the previous variety by the more 
extensive hemorrhages that take place, ecchymoses forming 
rather than petechiae, and by free bleeding from all the 
mucous membranes — nose, mouth, stomach, urethra, rectum, 
vagina. These are so copious and uncontrollable at times 
that the patient will literally bleed to death in a few hours. 
Sudden death may also be caused by hemorrhage into the 
meninges and brain. An excellent study of this fulminat- 
ing form of purpura has been made by Lockwood. 1 In his 
case there was a rise of temperature of 106.2° F. just be- 
fore death, and the patient died in about sixty hours from 
the onset of the disease. He collected thirty cases, in 
thirteen of which the patients died from acute anaemia, in- 
ternal hemorrhages, or septic infection, the shortest duration 
of any one case being seven hours ; in eight cases death 
was due to cerebral hemorrhage ; and in four cases the 
patients were pregnant. Happily all cases of hemorrhagic 
purpura are not fatal. In them the bleeding is moderate in 
amount, and the patient is gradually restored to health. 
Relapses may occur. 

Purpura Fulminans is the name applied to those very 
grave cases of purpura in which the patient dies in a short 
time. It is a form of purpura hsemorrhagica. It may 
affect several members of the same family, which suggests 
its infectious nature. It has followed scarlatina. 

Purpura Rheumatic a. This is also called peliosis rheu- 
matica. It resembles purpura simplex in every way, ex- 
cepting that the outbreak of the eruption is preceded or 
followed by pain in the joints accompanied by swelling, the 
malaise is more marked, and there is often rise of tempera- 
ture. The eruption is often most abundant about the joints. 
The acute symptoms subside in two or three days, but re- 
lapses are frequent. True rheumatism may be present at 
the same time. Valvular heart lesions have been reported 
to occur after this variety of purpura, even without true 

1 Medical Record, xxxix. 155, 1891. 
19* 



430 DISEASES OF THE SKIN. 

rheumatism. Rarely this variety may pass over into the 
hemorrhagic form. 

Etiology. Many causes have been assigned to account 
for the occurrence of purpura. We know that it may occur 
at any period of life, in both sexes, and in the most varying 
conditions of health. We meet with cases in the spring 
and autumn, in weather that is damp and cold. There is 
no doubt that purpura occurs as a symptom in different dis- 
eases and cachexise; after the ingestion of certain drugs, 
and under other circumstances too numerous to catalogue 
here. Here we can readily surmise that one or both of two 
things have occurred, namely : a change of the blood itself 
that allows of its passing through the walls of the vessels ; 
or a change in the vessel walls themselves that permits the 
blood to pass through them. Purpura has been noted after 
the loosening of some artificial support to a part of the 
body, such as a tight bandage worn for a long time. 
It occurs not infrequently in old age. In both these con- 
ditions it is due to a weakening of the tone of the vessels. 
In the former case matters right themselves in a few days 
— a happy conclusion that cannot be anticipated in the 
latter case. Weakness of vascular walls may also be the 
cause of those somewhat rare cases of purpura without 
cachexia seen in infants. Other cases of purpura are due 
to small thrombi lodging in the smaller vessels. Some 
cases seem to be due to vasomotor or tropic nerve action 
causing either sudden alterations in the calibre of the 
vessels or degenerations in their walls. Recurring pur- 
pura has been noted about the point of greatest pain in 
neuralgia. 

The microbian and infectious origin of purpura is stoutly 
defended by some authorities. Some authorities believe 
that purpura occurring in an infectious disease is due to 
micro-organisms. Letzerich 1 published a brochure on this 
subject in 1889, in which he described the " bacillus pur- 
purse hemorrhagica Letzerich " as the cause of the disease. 
This has sharp angles and edges, is readily cultivable, and 

1 Monatshefte f. prakt. Dermat., 1889, p. 312. 



PUEPUBA. 431 

pure cultures injected into rabbits give rise to hemorrhages 
either spontaneously or on slight trauma. 

Diagnosis. The diagnosis of purpura is easily made. 
No other disease produces bright-red, slightly elevated lesions, 
the color of which cannot be made to disappear under pres- 
sure. From flea-bites they are distinguishable by the ab- 
sence of a central punctum. Purpura hemorrhagica bears 
a close resemblance to scurvy, but in the latter a dietary 
deficient in vegetables is a marked etiological factor ; there 
are also greater prostration, swelling of the gums, loosening 
of the teeth, and brawny swelling of the limbs. It is possible 
that further investigations of scurvy may show that it is but 
a form of purpura hemorrhagica that has been modified by 
diet. 

Treatment. In simple purpura there is not much to be 
done except to put the patient in as good a hygienic condi- 
tion as possible and relieve symptoms. In peliosis rheu- 
matica and purpura hemorrhagica the patient should be 
kept absolutely quiet in bed, his diet should be of the most 
nutritious and easily assimilable kind, and ergot and iron 
administered. Of course, if there is hemorrhage from the 
nose, vagina, or other mucous cavity an effort must be made 
to stop the flow by means of a tampon, ice, hot water, or 
any method that experience has proved useful. Ergotine 
may be employed hypodermatically ; and turpentine ; dilute 
sulphuric acid ; nitrate of silver in pill-form -J- to \ of a 
grain three times a day ; and other astringents have been 
found useful. Letzerich recommends for bleeding from the 
gums — 

Be • Tinct. ratanhiae, 10 parts. 

Tinct. iodiiri, 5 " M. 

of which 10 drops are to be put in a wineglassful of water. 
For this purpose other astringents, as tannin, alum, and the 
like, may be used. 

Prognosis. From the beginning of a case it is not pos- 
sible to say how it will turn out. We should therefore be 
very guarded in our prognosis. Most cases met with termi- 
nate favorably. Some apparently desperate cases recover. 



432 DISEASES OF THE SKIN. 

Pustula Maligna. Synonyms: Anthrax; Malignant 
pustule ; (Fr.) Charbon. 

This is a disease of cattle, sheep, and horses, in which it 
is called splenic fever, and is due to local inoculation with 
the bacillus anthrax, often through the agency of flies. If 
the bacillus gains access to the internal organism, it produces 
a rapidly fatal general disease with no skin lesion. In the 
human the exposed parts — face, hands, and neck — are the 
most frequent sites of the disease. In a day or two after 
inoculation the patient notices a burning or itching of the 
affected part and the formation of a livid-red papule upon 
which a bulla or pustule soon forms. This ruptures, the 
red spot changes into a black gangrenous eschar, the parts 
around it become indurated, oedematous, of dusky red hue, 
and studded with small vesicles or pustules. There is 
marked involvement of the lymphatics, and enlargement of 
the neighboring glands that may suppurate. In favorable 
cases the slough separates, and healing by granulation takes 
place. In fatal cases the gangrenous process extends 
rapidly, symptoms of septic infection declare themselves, 
and the patient succumbs to the disease in from two to eight 
days. In all cases there is more or less constitutional dis- 
turbance. 

Diagnosis. The diagnosis of malignant pustule is made 
mainly by the rapidity with which the disease develops ; the 
presence of the gangrenous patch with the hard indurated 
tissues about it ; and the severity of the constitutional 
symptoms. The finding of the bacillus will verify the 
diagnosis. 

Treatment. The total excision of the diseased patch by 
means of a free incision is the most radical and effectual 
treatment for the disease. Injection of iodine or a 5 per 
cent, solution of carbolic acid under the eschar are good 
methods of treatment. The hyposulphite or sulphite of 
soda, and large doses of quinine, are worthy of trial. 

Quinquaud's Disease. See Folliculitis decalvans. 

Radesyge. See Lepra. 

Raynaud's Disease. See Dermatitis gangrenosa. 



RHINOSCLER OMA. 



433 



Red Gum. " An obsolete term for various transitory 
eruptions in teething children." (Foster.) Commonly 
this is miliaria. 

Rheumatokelis. A term applied by Fuchs to purpura 
occurring with rheumatism. 

Rhinophyma (Rrm-o-fi'ma 3 ) is the term used to designate 
that form of hypertrophic rosacea in which pendulous tumors 
develop on the nose. These may attain so great a size that 
they hang down over the mouth. See under Rosacea. 

Rhinoscleroma (Rrm-o-skleVo'ma 3 ). Synonyms: (Fr.) 
Rhinosclerome ; (Ital.) Rinoscleroma ; Perisarcoma. 

Fig. 50. 




Rhinoscleroma. 



Symptoms. This is an exceedingly rare form of disease 
that was first described by Hebra and Kaposi. It affects 
almost exclusively the nose and its mucous membrane, and 
assumes the form of flat or slightly raised, sharply defined, 
isolated or confluent, very hard, lobulated, elastic plates, 
tumors, or nodes which are painful on pressure. These 
lesions are located in the skin or mucous membrane of the 



434 DISEASES OF THE SKIN. 

septum of the nose, or in the alse and the neighboring parts 
of the upper lip. They can be raised from the underlying 
parts, but the skin is so infiltrated that it can move only 
with the growths. The color of the skin may be normal, or 
bright or dark brownish-red. They may look like a keloid or 
hypertrophied scar. The contiguous skin shows no abnor- 
malities whatsoever. The epidermis over the growths often 
shows rhagades from which exude a viscid secretion which 
dries into yellowish adherent scabs. 

The disease begins as a thickening and hardening of the 
septum of one or both alse without inflammatory reaction or 
pain. Slowly the nose becomes deformed, broad, and flat, 
and at last by progressive thickening of both septum and 
alse the nostrils become occluded. The process may involve 
the lips so that the opening of the mouth becomes greatly 
lessened, and may affect the gums. More frequently it pro- 
ceeds backward along the nostrils on to the velum palati. 
The growth shows no tendency to ulceration or retrograde 
metamorphosis. At the most superficial parts excoriations 
occur. Late in the disease the teeth may loosen and fall 
out, and the gums may atrophy. The disease may begin 
in some cases in the pharyngeal vault. The epiglottis and 
larynx may be involved in the process, and aphonia, suffo- 
cative or epileptic-like attacks may occur. There is no con- 
stitutional disturbance, and the only subjective symptoms 
are those of discomfort on account of the interference with 
respiration. The disease is steadily progressive ; shows no 
tendency to recovery; and recurs rapidly when the diseased 
parts are cut away. 

Etiology. All conditions of men are affected, and both 
sexes with about equal frequency. It usually begins be- 
tween the fifteenth and fortieth year. It is most frequent 
in warm climates, and is specially prevalent in Austria and 
Russia. A bacillus has been found in the tissues by Frisch 
that is regarded as the cause of the disease. It is described 
as short, thick, ovoid, capsulated, in free groups and in cells. 

Diagnosis. The location upon the nose and upper lip 
alone, the ivory-hardness of the growths, and their pro- 
gressive course without tendency to ulceration or softening, 



ROSACEA. 435 

will establish the diagnosis as against syphilis, epithelioma, 
and sarcoma. Keloid rarely occurs upon the nose, and 
never runs the characteristic course of rhinoscleroma. 

Treatment. Treatment is very unsatisfactory. The 
growths may be excised or curetted away, but neither pro- 
cess will assure against a relapse. The nostrils may be 
kept open by means of sponge-tents and the like. Besnier 1 
recommends boring into the tissues with points of chloride 
of zinc for the purpose of giving passage to air. Pyrogallic 
acid, 10 per cent, in vaseline, has been recommended as of 
value. 

Prognosis. The prognosis is bad. The disease is pro- 
gressive, and threatens life by suffocation on account of 
involving the larynx. 

Rlms-poisoning. See Dermatitis venenata. 

Ringed Hair. See Canities. 

Ringskurv. See Trichophytosis. 

Ringworm. See Trichophytosis. 

Rissopola Lombarda. See Pellagra. 

Ritter's Disease. See Dermatitis exfoliativa neonato- 
rum. 

Rodent Ulcer. See Epithelioma. 

Rosacea (Ros-a'ce-a 3 ). Synonyms : Acne rosacea ; 
Grutta rosacea seu rosea ; Acne erythematosa ; (Fr.) Acne 
rosee, Couperose, Rosacee, Ros6e; (Ger.) Kupferrose, 
Kupferfinne, Kupfrigegesicht. 

A chronic disease of the skin, limited in most cases to 
the middle third of the face from above downward, and 
characterized by a diffused or patchy redness made up of 
dilated capillaries. 

This disease is very commonly called acne rosacea, but 
inasmuch as the papules that often occur with the disease 
are not true acne pustules, it is best to drop the "acne" 
from its title. 

1 Annal. Derm, et Syph., 1891, ii. 603. 



436 DISEASES OF THE SKIN. 

Symptoms. Rosacea is one of the more common skin 
diseases, and is peculiar in affecting, with few exceptions, 
only the middle third of the long diameter of the face, the 
forehead, nose, and adjacent portions of the cheeks, and the 
chin. The nose may be affected alone, and in many cases 
the forehead escapes entirely. The disease has three forms 
or stages. The first consists in a simple redness of the 
affected skin with more or less well-marked dilatation of the 
capillaries. In the second stage there is an added element 
of superficial papules and pustules, and perhaps nodules. 
In the third stage there is marked hypertrophy of the skin. 
The process may stop at any stage. An oily seborrhoea 
may complicate the disease, Unna even claiming that his 
seborrhoeal eczema is the first stage of all cases of rosacea. 

The first stage varies in degree. At first there may be 
faint flushing of the skin, as after the ingestion of hot fluids, 
exposure to cold, and the like. This being repeated, perma- 
nent dilatation of the capillaries takes place. The dilated 
capillaries are not evident all over the patch. The greater 
part of the patch may present an even redness. The 
border of the patch is ill-defined, and no matter how fiery 
red the color may be the skin feels cool to the touch. This 
is because the congestion is passive on account of a slug- 
gish circulation. In some cases, however, there may be but 
little general redness, only a number of dilated capilla- 
ries. These telangiectases are best seen on the nose. In 
some cases there may develop a congestive seborrhoea or 
even an erythematous eczema, which, yielding to appro- 
priate remedies, leaves behind an undoubted rosacea. 

The second stage may develop from the first after the 
latter has lasted a considerable length of time, or be almost 
coincident with it. The number of papules and pustules 
may be considerable, and the tubercles large. If so, the 
amount of redness will be great. The peculiar feature of 
the pustules is their superficiality. They are usually quite 
small, say of pin-head size, and when pricked give exit to 
but a small drop of thin pus. The tubercles are enlarged 
or clogged sebaceous glands, but all these lesions are but 
secondary to the chronic hyperemia, and not primary, as in 



ROSACEA. 



437 



acne. There may also be comedones and true acne scat- 
tered over the face. 

While the majority of cases never go beyond the second 
stage, in some cases the continued and excessive hyperemia 
leads to an increase of connective tissue, and the nose, tip 
and sides, becomes converted into a lobulated mass of tis- 
sue, sometimes so great as to form pendulous tumors hang- 
ing down over the mouth. This last condition is known 
as rhinophyma. The whole nose is of deep-red or purple 

Fig. 51. 




Rhinophyma. (Lassar.) 



color, and studded over with crater-like openings, leading 
down into the thickened mass. At times ulceration occurs 
in these crypts and causes additional annoyance and de- 
formity from destruction of tissue. 

While in the vast majority of cases the middle third of the 
face alone is affected, in some cases the whole face becomes 
red, and the redness may extend down upon the neck. 
Rosacea is seen at times on the scalp of bald-headed per- 
sons just above the forehead. 



438 DISEASES OF THE SKIN. 

Etiology. The cause of the disease is probably a vaso- 
motor reflex neurosis. Schwimmer regards it as a tropho- 
neurosis ; Unna as a seborrheal eczema. It occurs in adult 
years, most frequently after the twenty-fifth or thirtieth 
year, though it may occur even at puberty. There is no 
connection between it and acne. While many patients will 
tell you that they had "pimples" when young, as many will 
inform you that they have always had a good complexion 
until the rosacea began. Women are more frequently af- 
fected than men. Digestive disturbances are a very common 
cause of the disease, and the trouble may be located either 
in the stomach, intestines, or accessory digestive organs. 
Drinking of spirits will undoubtedly cause it, on account of 
producing both gastric catarrh and reflex dilatation of the 
facial vessels. The inordinate use of strong tea acts in the 
same way, and probably gives rise to as many cases as does 
alcohol. Exposure to the weather or to extremes of tem- 
perature will cause rosacea without digestive disturbances, 
but when combined with the latter leads on to the most 
brilliant examples of it. Constipation, menstrual derange- 
ments, anaemia, chlorosis, the menopause, each one has been 
noted in connection with rosacea. The use of cosmetics has 
been followed by it. Various morbid conditions of the mu- 
cous membrane of the nose have been found in connection 
with it. Tight lacing is frequently followed by rosacea. 

Pathology. In the first stage there is dilatation of the 
bloodvessels in the cutis. In the second stage these are 
more pronounced, and the corium is slightly thickened and 
edematous in places. In the third stage there is in addi- 
tion enormous hyperplasia of the connective-tissue elements 
of the cutis, and the sebaceous glands are enlarged. (Elliot.) 

Diagnosis. When we meet with a case of redness, with 
or without papules, pustules, or tubercles, that is limited to 
the middle third of the vertical diameter of the face, it is 
probably one of rosacea. It differs from acne in its limited 
area, the superficial character of the pustules, the absence of 
comedones, and the capillary dilatation. Lupus erythema- 
tosus may occur in the same location, but in it we do not 
find the dilated capillaries ; but we do find thickening of 



ROSACEA. 439 

the skin, adherent scales with prolongations from their 
under side, a sharply defined, slightly raised border to 
the patches, and, if the disease has lasted any time, more 
or less delicate cicatricial tissue. In its early stage the di- 
agnosis is not always easy. Lupus vulgaris should not con- 
fuse us, as in rosacea there is an entire absence of the char- 
acteristic apple-jelly-like tubercles of lupus. The tubercular 
syphilide may resemble rosacea in its second or third stage, 
but soon it undergoes softening and ulceration — processes 
that do not occur in rosacea. Moreover, it is not symme- 
trical, but occurs in the form of groups of tubercles, presents 
no telangiectases, and evidences of other syphilides are usu- 
ally to be found. Erythematous eczema burns and itches, 
the skin is somewhat swollen and scaly, and feels harsh and 
leathery. Sometimes an eczematous condition complicates 
a rosacea, and the latter declares itself onlv when the former 
is cured. 

Treatment. In order to treat rosacea successfully we 
must first endeavor to remove the cause. We must inquire 
as to the condition of the digestive apparatus, the manner in 
which menstruation is performed, exposure to heat and cold, 
and, in fact, ascertain the patient's general condition. Then 
we must address ourselves to the regulation of any deranged 
function. We must stop the use of alcoholics in any form, 
and the ingestion of all hot fluids, such as tea, coffee, and 
soup. All these tend to produce dilatation of the blood- 
vessels of the face and to keep up those conditions we wish 
to remove. The patient's diet should be carefully regu- 
lated, and such things as pastry and sweets cut off, so as 
to make digestion as easy as possible. Medicinally, tincture 
of nux vomica, the mineral acids, or alkalies are to be ad- 
ministered q. r. n. Nux vomica has often seemed to render 
good service, even without there being marked digestive dis- 
turbance. Salol is a good remedy in many cases of intes- 
tinal fermentation. Ergot or ergotin proves useful in some 
cases, either with or without uterine disturbances. Ichthyol 
is commended by Unna. The ammonio-sulphate is the 
preparation to use, and it is best given in capsules to cover 
the taste. The dose is three drops two or three times a day. 



440 DISEASES OF THE SKIN. 

In a rather extensive trial of this by me in some sixty 
cases in which it was used alone, with no external applica- 
tion, the result was unsatisfactory, only one or two cases 
being benefited. 

The local treatment is important in hastening a cure, but 
is not of itself curative in well-marked cases of reflex rosacea. 
The patient must be instructed to protect the skin from the 
action of wind and weather, by either applying some oint- 
ment, such as vaseline, or a powder, such as cornstarch, be- 
fore venturing out of doors. Then the face should be bathed 
in hot water every night before going to bed, the water being 
as hot as the skin can stand without burning, and it should 
be sopped on for about ten minutes, freshly heated water 
being added from time to time, so as to maintain a uniform 
temperature. This is beneficial because the primary dilata- 
tion of the vessels is followed by contraction. After the 
bathing the following lotion should be applied : 



H. Zinc, sulphat., \ ~ • . 3 

Potass, sulphuret, J ^ J ' 

Aquse rosse, ad ^iv; 100 



M. 



It is, perhaps, as good as any application we can make. 
Van Harlingen gives another good one as follows,: 

J& . Sulphur, praecipitat., . 3 j ; 

Pulv. camphorse, gr. v 

Pulv. tragacauth., gr. x; 1 



Aquae rosse, 1 .- z . 1AA 

T - 1 1 • > aa z i : 100 

Liq. calcis, J OJ ' 



M. 



Instead of lotions, sulphur ointment (3j-oj), or the white 
precipitate ointment may be used, or simply powdered 
sulphur. In obstinate cases Vleminckx's solution may be 
used. It is composed as follows : 



&. Calcis, 


3iv; 


5 


Sulphur, sublimat., 


5j; 


10 


Aquae destillat , 


3 x ; 


100 



M. 



Boil together, with constant stirring, until the mixture 
measures six fluidounces, then filter. 

This is to be diluted four or five times at first, and used 
at night only, followed by cold cream in the morning. The 



ROSACEA. 441 

dilution is to be lessened by degrees. Any of these reme- 
dies may produce a dermatitis, followed by desquamation, 
which is to be desired. For this purpose we may use re- 
sorcin, 10 to 20 per cent, in vaseline, stopping it when the 
skin begins to peel, when the skin is to be dressed with cold 
cream until the irritation has subsided. Then the resorcin 
is to be used again. Hillairet 1 recommends washing the 
face in the morning with hot water, followed by a solution 
of oxide of zinc, three or four grains to the ounce, sopped 
on for half an hour. Before going to bed the following is to 
be applied to the face : 



$ . Camphorated alcohol, 8 ad 15 

Sublimated sulphur, 30 

Distilled water, 250 



M. 



After six days this is to be discontinued for a couple of 
days, and then begun again. Ichthyol, in 5 to 10 per 
cent, strength in aqueous solution, has been highly extolled 
by Unna and others, as well for external as for internal 
use, and in many cases does well. 

If the case is highly inflammatory when first seen, our 
first attempts should be in the direction of reducing the 
inflammation by means of soothing ointments. After a few 
days we can begin the treatment of the rosacea. 

Surgical procedures are necessary to hasten the removal 
of pustules, and to destroy dilated vessels and hypertrophic 
tissue. Pustules are quickest removed by the curette, as in 
acne. Dilated vessels are best destroyed by electrolysis with 
the electric needle attached to the negative pole, introduc- 
ing it perpendicularly into the vessel at one or more points 
of its course, and letting it remain for a few seconds until the 
vessel appears as a white line. The method of using elec- 
trolysis is more fully described under hypertrichosis. It is 
often necessary to repeat the operation several times before 
the vessel is destroyed. The thermo-cautery may also be 
used in the same way. Multiple scarification is most useful 
in reducing red patches. It may be done by means of a 

1 Prog. Med., 1880, viii. 182. 



442 DISEASES OF THE SKIN. 

scalpel, making parallel lines near together and through the 
skin, and then a second series over these ; or a multiple 
scarifying-knife, as sold in the shops, may be used for the 
purpose. After scarifying, bleeding should be encouraged 
for a few moments by the application of hot water. Then 
the surface should be swabbed over with a solution of car- 
bolic acid, two drachms to the ounce of glycerin and water. 
This will check the bleeding and constringe the vessels. 
No after-treatment is needed, as a rule. ]f reaction tends 
to go too far, a soothing ointment may be applied. The 
operation should be repeated once every week or two. It is 
astonishing to see how rapidly the redness will be reduced 
in many cases, and this without deformity being caused. 
Multiple scarifications may be employed for the reduction of 
tuberculated masses, but trimming off the superfluous tissues 
is a more speedy method. 

Prognosis. In cases of rosacea arising from exposure to 
weather in drivers and sailors, and those following similar 
pursuits, we cannot expect to effect a cure, as the patients 
cannot do the one thing necessary — give up their occupa- 
tions. In most all other cases we can promise great amelio- 
ration of the annoying redness, and in many we can effect a 
cure ; but we had best not attempt to treat a case that will 
not follow our directions as to diet and hygiene. 

Rose. See Erysipelas. 

Rosee. See Rosacea. 

Rose Rash. See Erythema. 

Roseola. See Erythema roseola. 

Roseola Pityriaca. See Pityriasis rosea. 

Roseola Syphilitica. See Macular syphilide. 

Roseole Squameuse. See Pityriasis rosea. 

Rbtheln (RuVe 2 ln), Rubeola or German measles, is a mild 
contagious disease that resembles measles, but differs from it 
in the mildness of all its symptoms, in the lighter color and 
smaller size of its lesions, and in the absence of the crescentic 
arrangements of them. Like measles, it may be mistaken 



SARCOMA. 443 

for either an erythema or an erythematous syphilide, and its 
diagnosis is along the same lines as is that of measles, which 
see. It is not so blotchy as measles, and the catarrhal 
symptoms are absent or but slight. Swelling of the glands 
of the neck is a symptom that may or may not be present. 
Febrile movement is slight. The lesions may take the form 
of small papules, and assume rather a brownish than a red 
color. The eruption is often itchy, and the lesions may 
occur on the mucous membranes. It differs from scarlatina 
in the mildness of all its symptoms, and in the absence of 
the diffuse scarlet eruption of the latter disease. 

Rothlauf. See Erysipelas. 

Rbtz. See Equinia. 

Rupia. See Syphilis. 

St. Anthony's Fire. See Erysipelas. 

Salt-rheum, See Eczema. 

Salzfluss. See Eczema. 

Sarcocele of the Egyptians. See Elephantiasis. 

Sarcoma (Sa^k-o'ma 3 ). We are here interested in sar- 
coma of the skin alone. Sarcomas may be primary in the 
skin, but most often they are secondary. They form 
variously sized tumors, but tend to run a malignant course, 
multiplying more or less rapidly, breaking down, affecting 
internal organs by metastasis, and killing the patient in a 
few months or years. There are three types of sarcoma — 
namely, the round-cell sarcoma, the small-cell sarcoma, and 
the melano or pigment sarcoma. Yery commonly sarco- 
mata are of mixed type ; or sarcomata may be divided into 
two varieties — the pigmented and the non-pigmented. 

According to Brocq, 1 who, following Perrin, has made an 
exhaustive study of the disease, primary melanotic sarcoma 
originates frequently from an irritated nsevus, or other pig- 
mented lesion, but may occur independently. At first, it is 
always single and small. It tends to enlarge and attain the 

1 These de Paris, 1885. 



444 DISEASES OF THE SKIK 

size of a nut. In shape it is oval or spherical. It is 
nearly always sessile. Its color is dark-blue or black. It 
is very hard to the touch. It may remain stationary for a 
long time, but in course of time new tumors will appear, 
either about the original one or at distant points by means 
of the lymphatics. Some of the original tumors will dis- 
appear, while new ones appear ; some will break down and 
form irregular ulcers whose floors are black and uneven, and 
secreting a thick, melanotic liquid, or a little pus, or almost 
solid black matter. A large lobulated mass may be formed 
by the coalescence of a number of smaller lesions. The vis- 
cera become involved, and death soon occurs. 

A rare form of melanotic sarcoma is described by Hutch- 
inson as melanotic whitlow, which at first is a chronic ony- 
chitis, the border of which looks like a lunar-caustic stain. 
It very gradually develops into a fungating tumor, slightly 
pigmented. The nail is shed, and generalization occurs 
(Crocker). 

Non-pigmented primary sarcoma may be generalized or 
localized. The generalized form begins usually upon the 
extremities, and causes upon the hands and feet a peculiar 
hard oedema, accompanied by tension of the skin, and per- 
haps itching or pricking. It may begin as brownish-red, 
livid, purple, or blue patches, upon which little pin-head-size 
nodules appear, which gradually enlarge. In some cases 
little, infiltrated, isolated, blue or reddish-brown nodes will 
form. Sometimes the first appearance will be a diffused 
cyanotic patch, which later will become a bossy elevated 
patch. When the disease is fully developed the hands and 
feet are thick, deformed, infiltrated, as firm as cartilage, 
brown or blue with a red tint. The skin is glossy, scaly, 
uneven. The nodes may be raised, pedunculated, or ulcer- 
ated. Similar lesions are found upon the rest of the body, 
though rarely on the trunk. They may remain stationary, 
disappear, fall off, multiply, ulcerate, or, finally, involve the 
mucous membranes, and cause death. 

The localized form develops ordinarily from an irritated 
nsevus, and is most often encountered on the extremities. It 
forms a hard, wrinkled tumor, which may ulcerate. Its 



SARCOMA. 445 

color is usually that of the normal skin, though it may be 
red. It may grow to be the size of an orange or take on a 
mushroom-like form. It may not generalize for a long time, 
or it may do so spontaneously, or after an attempt at removal. 

Sarcomas are very vascular, and are subject to profuse 
hemorrhage when injured or when they ulcerate. 

Etiology. We know very little in regard to the etiology 
of sarcoma. It occurs at all ages, some of the most malig- 
nant cases being seen in childhood. Brocq says that the 
localized non-pigmented sarcoma is most frequent in women, 
and that the generalized form is most frequent in robust men 
of forty to sixty years. Piffard gives the ages at which they 
are most prone to occur as before the fifteenth and after the 
forty-fifth year. 

Diagnosis. The diagnosis of sarcoma is generally easy, 
but at times it is difficult. The pigmented forms are usually 
readily recognizable by their color. The non-pigmented 
single sarcoma may be distinguished from epithelioma by 
its feel, which, though firm, lacks that stony hardness 
that is characteristic of cancer. Fibromata are not so firm 
as are sarcomata, are more commonly pedunculated, and 
show no tendency to degenerative changes. Mycosis fan- 
goides has a primary eczematous stage ; its tumors are of a 
brighter red and they come and go, and undergo various 
changes much more rapidly than do sarcomata. 

Treatment. Excision of a single non-pigmented sar- 
coma is often curative. In multiple sarcomata, and in the 
melanotic variety, operative interference is usually not only 
not curative, but has often seemed to hasten generalization. 
Kobner and others have used hypodermatic injections of 
arsenic with brilliant results in some cases. Kobner used 
Fowler's solution of half strength, and injected two and a 
half to four drops of it once a day. After three months the 
dose was increased to seven and a half, and then to nine 
drops. Others have tried arsenic without effecting a cure. 
Still it is worthy of trial, as it may cure the disease if it is 
well borne by the patient. Inoculation by the toxin of the 
streptococcus has cured some cases, but its use is not with- 
out danger to the life of the patient. 

20 



446 DISEASES OF THE SKIN. 

Prognosis. This is always grave. The course of the 
disease is nearly always from bad to worse, though the fatal 
result may not be reached for many years. Melanotic sar- 
coma is more rapidly fatal than is the ordinary form. 

Satyriasis. See Lepra. 

Scabies (Skab'i 2 -ez). Synonyms : The Itch ; (Fr.) Gale ; 
(Ger.) Kratze. A contagious disease of the skin due to its 
invasion by the acarus scabiei and characterized by exces- 
sive itching, worse at night, and by excoriated lesions, pus- 
tules, and cuniculi upon the anterior face of the wrists, be- 
tween the fingers, on the breast of women, the penis of males, 
and about the umbilicus of both sexes. 

Symptoms. The popular name of scabies, which is the 
Itch, gives us at once one of the marked features of the dis- 
ease. Itching is always present in it. While it may be 
somewhat in abeyance during the day, it is hardly ever ab- 
sent, and at night in bed it is so bad, in susceptible indi- 
viduals, that sleep is well-nigh impossible. The itching 
gives rise to scratching, and the scratching to the secondary 
symptoms of the disease — scratched papules and eczematous 
patches. 

The first thing that the patient notices is that his skin 
itches. To relieve this he scratches, and sooner or later, 
according to the resistance of his skin, he produces pin-head- 
size excoriations. Later, the irritation continuing, eczema- 
tous patches result. When he presents himself to the physi- 
cian, the latter will find on examination excoriations due to 
scratching, and he will notice that the lesions are located 
principally between the fingers, on the anterior surface of 
the wrists and somewhat on the forearms, about the axillae, 
upon the breasts about the nipples in women, upon the male 
genital organs, about the umbilicus and lower part of the 
abdomen, and often upon the buttocks of both sexes, and, 
in children especially, upon the anterior surface of the ankles 
and between the toes. In adults, these latter situations are 
not so frequently affected. Closer examination may be re- 
warded by the discovery of the pathognomonic sign of 
scabies — namely, the cuniculus, or burrow, which is usually 



SCABIES. 447 

found most readily on the inner border of the hand, on the 
inside of the fingers, and on the penis. It forms a delicate, 
slightly raised, whitish or grayish, wavy, often bowed line, 
about one-eighth to one-half an inch in length, and having 
a white speck at one end which marks the place where the 
itch-mite is. These are not always to be found ; indeed, in 
most cases they are difficult to find, because they are broken 
up either by the occupation of the individual, by the use of 
soap and water, or by scratching. In people with delicate 
skin the burrowing of the itch-mite will set up an inflamma- 
tory process, and papules, vesicles, and pustules will form, 
quite independently of the scratching. 

While the regions mentioned are the ones always affected 
in well-marked cases, variations in the extent of the disease 
are observable. In some cases the hands are free, and but 
few lesions are present anywhere. Here, if it is a male, the 
crucial test will be the examination of the privates, where a 
scratch-mark or a burrow will be found almost without fail. 
In other cases, hardly any part of the body will be free from 
excoriations, pustules, or eczematous patches, excepting the 
face, which is affected only exceptionally, and then nearly 
always in children. In these bad cases furuncles and large 
ecthymatous pustules join themselves to the already multi- 
form eruption of scabies. Urticaria is also present in some 
cases, its wheals being interspersed among the other lesions. 
Should some intercurrent fever arise, the symptoms of scabies 
will subside, to reappear when the fever is past. The so- 
called Norwegian Itch is only a very much aggravated form 
of the disease, on account of the want of personal cleanliness 
of the people. The face in this form may be affected, the 
nails split and shed, and the palms and soles covered with 
thick crusts. 

Etiology. Scabies is due to the irritation set up by the 
acarus scabiei and by the scratching employed to relieve the 
same. The vesicles, papules, or pustules about the burrows 
are due directly to the acarus ; it may be on account of 
some irritating substance secreted by it. The disease is 
contagious, but requires prolonged contact, as by holding of 
hands, or sleeping with an infected person. It is very rare 



448 DISEASES OF THE SKIN. 

for it to be communicated to a physician in examining a 
patient. 

According to Greenough, 1 it is most prevalent between 
the ages of five and thirty, and comparatively rare after the 
fiftieth year. This, he thinks, is due to the fact that in ad- 
vanced life the epidermis becomes harder and dryer, and 
forms a less suitable habitat for the acarus. Ten years ago 
the disease was not common in this country, but now it is an 
every-day occurrence to meet with new cases in our dispen- 
saries, and not an infrequent one to meet with it in private 
practice. 

Pathology. The acarus scabiei is very small, being 
barely visible to the naked eye, the female being but one- 
sixtieth to one-eightieth of an inch long, and the male still 
smaller. Its width is about two- thirds of its length. It 
has eight legs — four on each side of its head, to which 
suckers are attached, and four posteriorly, to all of which, in 
the female, bristles are attached ; while in the male the 
inner ones are wanting in bristles, but provided with suck- 
ers for attaching himself to the female in copulation. On the 
back are a number of short bristles. A glance at the accom- 
panying plates will describe the animal better than words. 

The female acarus having landed on the skin, soon stirs 
about, and having found a suitable place, it rests on its hind 
feet, takes an oblique position, pierces the skin, and bores a 
hole, into which it forces itself. It lodges in the deeper 
layers of the epidermis, above, and sometimes in the mucous 
layer. It bores a burrow equidistant between the surface 
of the epidermis and the level of the papillae of the corium. 
Being prevented by the bristles on her back from moving 
backward, she moves forward, and lays her eggs. Her dura- 
tion of life is from six weeks to two months, and during this 
time she lays some fifty eggs. These hatch out, reach the 
surface of the skin, meet the male, become impregnated, bore 
in their turn into the skin, and so keep up the process. As 
the thinnest parts of the skin are most easily punctured, it 
is Justin these parts that we find the lesions most commonly. 

1 Boston Med. and Surg. Journ., Sept. 23, 1886. 



SCABIES. 



449 



The scratching often extends far beyond the sites of the 
burrows. Fournier found that an acarus died in seven 
days when immersed in cold water, in ten days when in 
warm water, and in two to four days in a solution of green 
soap. He denies the commonly accepted view that the 
acarus is a night-prowler, though he allows that it is most 
active at night. 

Fig. 52 . 




Acarus scabiei. Back. 



Diagnosis. The presence of pustules and scratch-marks 
between the fingers, on the anterior face of the wrists, about 
the umbilicus, on the breasts in women or the genitals in 
men, is enough to make the diagnosis of scabies. If a cunic- 
ulus can be found, it will be corroborative evidence. Eczema 
is more patchy and does not occur in the characteristic loca- 
tions of scabies. Pediculosis vestimentorum presents long, 
parallel scratch-marks instead of the small excoriations of 



450 



DISEASES OF THE SKIM 



scabies, and their characteristic locations are over the 
shoulders, about the girdle, and along the outside of the 
arms and the inside of the thighs where the seams of the 
clothing come. The itching of scabies is worst at night, 
while that of pediculosis is most marked in the daytime. 
Urticaria is a general disease characterized by wheals and 
shows no tendency to localize itself in certain regions. 



Fig. 53. 




Acarus scabiei. Under surface. 



Should urticaria complicate scabies, the wheals will be dis- 
seminated while the lesions of scabies will be most marked 
in their characteristic locations. 

Treatment. If the disease is recognized, there is no 
difficulty in curing it, though there are various methods em- 
ployed. Perhaps the oldest and one of the most reliable, 
though not the most rapid " cure/' is to have the patient 
take a warm bath with soap and water, scrubbing himself 



SCABIES. 



451 



throughly so as to remove as much of the old epidermis as 
possible. Then he should dry the skin with vigorous fric- 
tion, and rub into every diseased spot ordinary sulphur oint- 



Fig. 54. 




Burrow of scabies with acarus. (After Kaposi.) 



ment. When this is done he can smear the rest of the 
skin with the ointment, put on the same clothes, and go 
about his business. The rubbings with the ointment are to 
be repeated morning and night for three days, the patient 



452 DISEASES OF THE SKIN. 

wearing the same underclothing by day, and bed- and night- 
clothing by night. At the end of three days another bath 
is to be taken, the clothing changed, and the patient should 
then present himself for examination. If fresh lesions are 
found, a second course should be taken, which most always 
will be sufficient. An artificial eczema is apt to be set up 
by the sulphur, and as eczema itself itches we must not take 
the continuance of pruritus beyond the second course as 
evidence of the scabies not being cured. It is better to stop 
the sulphur for a few days, and put the patient upon a mild, 
protective dressing to his skin, such as vaseline and corn- 
starch. If the itching grows worse instead of better, a 
third course of rubbing must be gone through with. In- 
stead of plain sulphur ointment we can add balsam of Peru, 
about half a drachm to the ounce, or use the modified Wil- 
kinson's ointment, as follows : 

R. Sulph. sublimat., \ -- . 9A 

01. cadini, J aa 3 1V ' ZU 



Cretse preparat. , 3 ijss 10 

Sapo viridis, \ .. -. d 100 

Adipis I aa 3J , P- e. ad 1UU 



M. 



This, though a very efficient remedy, forms such a dis- 
gusting-looking mass and is so irritating that it is fit only 
for public practice. /9-naphthol, in 5 to 10 per cent, strength 
in ointment or oil, is a good remedy, free from the sulphur 
smell, and not so irritating. Kaposi recommends it in the 
following form : 

R . /3-naphthol, 1 5 parts. 

Sapo viridis, 50 " 

Cretse alb. pulv., 10 " 

Adipis, 100 " M. 

and Crocker says : " I can speak of it in the highest 
praise." It is well fitted for private practice. McCall An- 
derson extols styrax liquida with a double amount of lard. 
As the itch is very prevalent in Scotland, the doctor should 
know of what he speaks. Too free use of this remedy may 
cause a nephritis, so patients using it must be watched. 
The treatment in the St. Louis Hopital of Paris is a 



SCABIES. 453 

heroic one, but is said to cure in one hour and a half. Ac- 
cording to Fournier, the patient is scrubbed violently for 
half an hour with green soap ; then for another half-hour 
the scrubbing is continued while he is in a bath ; then he is 
rubbed with this ointment : 

HelmericKs Ointment. 



R. Potass, carbonat., 
Sulphur, sublimat., 
Adipis, 



ss; 


15 


j ; 


30 


iv; 


120 



M. 



200 


parts 


5 


u 


100 


n 


35 


tt 



Now he puts on his clothes without removing the salve, and 
is discharged cured. In private practice Fournier recom- 
mends the use of a good toilet soap for the preliminary rub- 
bings, and then Bourguignon's ointment as follows : 

&. Glycerini, 

Gum tragacanth, 

Sulph. sublimat., 

Potass, carb., 

01. lavandulae, ] 

OLmenthpip [ u L5Q u M 

Ol. caryopnylli, { 

01. cinnamomi, J 

This is to be followed by a bath and powdering with corn- 
starch. It cannot be used for children, or in extensive cases 
in adults where there is much excoriation. 

For infants and young children, balsam of Peru is about 
the pleasantest application we can make, it being rubbed in 
morning and night, either pure or diluted with sweet oil ; 
or a mitigated form of sulphur ointment may be used. 

Sherwell 1 commends rubbing in dry powdered sulphur 
after a bath. 

In all cases the clothing and bedding must be disinfected 
— washable things by boiling, and cloth clothing by baking 
or by ironing with a very hot iron. All affected members 
of the family must be treated at the same time. An irrit- 
able condition of the cutaneous nerves may last at times 

1 N. Y. Med. Journ., 1893, i. 432. 
20* 



454 DISEASES OF THE SKIN. 

long after the scabies is cured, and must not be mistaken 
for a still active itch. 

Prognosis. The prognosis is always good, provided the 
applications are made thoroughly enough. 

Scall or Scalled Head. See Favus. 

Scarlatina (Ska 3 r-la 3 -ti / na 3 ). Scarlet fever is an acute 
contagious eruptive disease, characterized by a quick rise of 
temperature at the beginning, redness of the fauces, a straw- 
berry tongue, and the appearance of a fine punctate scarlet 
rash, which, first appearing on the neck, chest, and flexures 
of the joints, rapidly spreads over the whole body. The 
redness may be even over all, so as to give a boiled-lobster 
appearance to the skin ; or the red points may be distinct, 
although close together. The redness usually disappears on 
pressure. Vesicles may appear. A great deal of constitu- 
tional disturbance and prostration are apt to attend the 
eruption, but convalescence is well established in the second 
week in uncomplicated cases. Abundant desquamation fol- 
lows the subsidence of the eruption, which continues for days 
or weeks. 

Diagnosis. There is often a striking resemblance be- 
tween scarlatina and erythema scarlatiniforme, and some 
other erythemata. (See Erythema.) 

Scherende Flechte. See Trichophytosis capitis. 

Schmeerfluss. See Seborrhcea. 

Schuppenflechte. See Psoriasis. 

Scissura Pilorum. See Atrophia pilorum propria. 

Sclerema. See Scleroderma. 

Sclerema Neonatorum (SkleVe'-ma 3 ). Synonyms : 
Scleroderma neonatorum ; Induratio telse cellulose ; (Fr.) 
Algidite progressive, L'endurcissement athrepsique (Grer.) 
Das Sclerem der Neugeboren. 

This happily rare disease was first differentiated from 
oedema neonatorum, according to Crocker, by Parrot, in 
1877. It may be primary, but most often it is secondary 
to some exhausting disease, such as pneumonia or intestinal 



SCLEREMA NEONATORUM. 455 

catarrh. It may be present at birth, and rarely occurs after 
the first ten days of life. It is characterized by hardness 
of the skin, which generally at first is circumscribed and 
affects the leg. It may be diffused from the first, or it 
soon becomes so, and extends to the lumbar regions, back, 
chest, and so all over the body, becoming universal by the 
fourth day. It may begin on the face, and it may stop be- 
fore becoming universal. It may be but slightly developed 
on the chest. At first the skin is pale and waxy ; later, it 
becomes livid and cold, and the child looks as if frozen. 
The skin becomes attached to the underlying parts, smooth, 
tense, and does not pit on pressure. Movement is impos- 
sible for the child, and the body may be raised without 
moving a joint. When the face is affected it is impossible 
for the child to nurse. Its respirations are greatly reduced 
in number, its pulse falls to sixty a minute, its temperature 
is below normal, its breath is cool, and it dies within a week. 
The primary congenital cases are either stillborn or die in 
one or two days. Localized cases sometimes recover, the 
hardness of the skin disappearing. 

Etiology. The cause of the disease is obscure. It is 
seen almost exclusively in foundling-asylums and among 
the very poor. It is, therefore, a disease of depressed 
vitality. Langer 1 regards it as the result of solidification of 
the fat, which in infants contains 31 per cent, of palmatin 
and stearin, that of adults containing 10 per cent. The fat 
in infants, he says, is nearly all concentrated in the subcu- 
taneous tissues, where it is five times as thick relatively as it 
is in adults. Naturally, an infant's temperature is higher 
than an adult's, and, if it is lowered by any depressing cause, 
the fat may solidify. Solidification may take place also 
under the action of cold, or by oxidation, as in fevers, with- 
drawing some of the constituents of the fat. Parrot regards 
the disease as one of desiccation from the drain of a diar- 
rhoea, or the like. 

Diagnosis. Sclerema neonatorum is differentiated from 
oedema neonatorum by being more general in its distribu- 

1 Wien. med. Presse, 1881, xxii. 1375. 



456 DISEASES OF THE SKIN. 

tion, by the skin being harder and more tense, and not 
pitting on pressure, and by the rigidity of the joints. 
Scleroderma occurs at a later age than does sclerema, and 
the skin lacks the coldness of the latter. There are no 
other diseases with which sclerema can be confounded. 

Treatment. The course of the disease is almost inevi- 
tably toward a fatal termination, and little more can be done 
than to keep the little body as warm as possible, to rub in 
oil, and to administer concentrated nourishment and stimu- 
lants. Money 1 reported a case in 1889 that was cured in 
six weeks by mercurial inunctions. There was no history 
of syphilis in the case. 

Scleriasis. See Scleroderma. 

Sclerodactylia. See Scleroderma. 

Scleroderma (SkleVo-du^m'a 3 ). Synonyms : Sclerema 
seu Scleroma adultorum ; Scleriasis ; Dermato-sclerosis ; 
Chorionitis ; Sclerostenosis ; (Fr.) Sclereme des adultes, 
Sclerodermic ; (Ger.) Hautsclereme ; Hide-bound disease. 

A subacute or chronic disease, characterized by hardness 
and rigidity of the skin. 

Symptoms. The name of this disease indicates the most 
peculiar feature of it — that is, hardness of the skin. It may 
come on without apparent cause, the patient first noticing 
the stiffness of the skin ; or it may follow exposure to damp- 
ness and cold, and be preceded by pains of rheumatic nature. 
It may begin in any part of the skin, but has a preference 
for the upper half of the body. It is usually symmetrical, 
though it may be more pronounced on one side than on the 
other. Having begun, it spreads, it may be very slowly, or 
it may be so rapidly as soon to involve large areas of the 
body. It often runs a capricious course, growing better and 
worse, and leaving sound areas in the midst of the diseased 
parts. There may be one patch or a number of them, and 
the patches assume many shapes, though most commonly 
they are elongated, running lengthwise of the limb. There 
are two varieties of the disease : 1. The infiltrating form. 

1 Lancet, 1889, i. 526. 



SCLERODERMA. 457 

In this there is a good deal of infiltration of the skin, which 
is hard, cannot be pinched up, does not pit on pressure, and 
is attached to the deeper structures. The appearance given 
to the affected part is cadaveric. In some cases there may 
be hard oedema. The affected part is usually on the level 
of the surrounding parts, though it may be slightly raised. 
The infiltration merges gradually into the neighboring parts, 
its border being ill- defined and more readily felt than seen. 
The natural folds of the skin are obliterated, erythema may 
be present at first, and telangiectases are frequently ob- 
served upon the surface. Not infrequently the patch has a 
lilac border. The color of the skin is paler than that of the 
normal integument, and in some places it may be that of 
ivory. Some scaling may be present, or pigmentation of a 
mottled or diffused character may give the patch a fawn to 
black color. Owing to the stiffness of the skin, the move- 
ment of the joints is interfered with, a state of pseudo-anky- 
losis being established. If the face is affected, it loses its 
expression, and the features become immobile. The eyelids 
may escape for some time ; but if the disease passes on to the 
atrophic stage, soon to be mentioned, the eyes become wide 
open and cannot be closed. If the chest is much affected, 
respiration is interfered with. The temperature of the skin 
is usually lowered one or two degrees. It may be normal, 
or somewhat elevated. Sensibility may be increased, nor- 
mal, or decreased. Pruritus is at times annoying. The 
secretions of the skin are lessened with the increase of the 
disease 

The disease may invade all the mucous membranes. 

To this form the second or atrophic form may succeed 
after months or years. Crocker thinks that it is probable 
that atrophy follows the oedematous infiltration only. When 
atrophy begins it is progressive, and the skin becomes dry, 
wrinkled, parchment-like. It is most often the upper part 
of the body that is affected — the face and arms. Continu- 
ous contraction of the skin produces an atrophy of the 
muscles under it, so that finally nothing remains of the 
original structures but the skin and bones, and the joints 
are ankylosed. The face being affected, we will find a 



458 DISEASES OF 1HE SKIN. 

corpse-like expression, wide-open eyes with ulcerated cor- 
neas, shrunken gums with loosened and falling teeth. The 
limbs being affected, slight injuries will produce ulcerations 
over bony prominences, and the limbs will be semiflexed. 
The sclerodactylie of Ball is scleroderma of the atrophic 
variety, affecting the hand and causing marked atrophy, 
loosening the joints, and distorting the hands, "so that the 
third and fourth fingers are curled up into the hand, the 
first and second are bent at the first phalangeal joint, while 
the thumb phalanges are overdistended." (Crocker.) 

The general health remains unaffected, often for years ; 
but should the disease be very pronounced, at last a maras- 
mic condition develops and death occurs. Apart from the 
pruritus and feeling of stiffness, we may have no subjective 
sensation, excepting that pain on pressure is exquisite. At 
times burning is complained of. The disease, when of the 
infiltrated variety, tends to a slow and interrupted course 
toward recovery. In the atrophic variety recovery may 
take place. Of course, the atrophied skin will never regain 
its natural texture, but the disease may cease to spread and 
increase. At best, its subject is but a sorry specimen. 

Children may have scleroderma, the youngest reported 
case being thirteen months. In them the disease is said to 
run a more rapid course, both in development and recovery, 
than it does in the adult. Vidal 1 describes a form of sclero- 
derma following a lesion of the skin, such as an eczema, 
which gives rise to a lymphangitis, and is usually met with 
on the leg. 

Etiology. Women are far more often the victims of 
scleroderma than are men — three to one. It is most com- 
mon in young and middle-aged adults. Apart from this, 
we are in uncertainty as to the true cause, though rheu- 
matism, gout, exposure to cold and heat, bad hygiene and 
poor food, and neurotic influences have each been found in 
apparent causative relation to the disease. At the founda- 
tion of the trouble there is supposed to be some defect in 
the nervous system, not improbably in the vasomotor center. 

1 Gaz. des Hop., 1878, li. 939. 



SCROFTJLIDE CRUSTACEE ULCEREUSE. 459 

Diagnosis. There is no other disease of the skin with 
which scleroderma could well be confounded, excepting 
sclerema or oedema neonatorum, morphoea, or cancer en 
cuirasse. The age at which the first two occur — namely, 
the first few days of life — would throw them out. 3forphoea 
is a localized scleroderma, and the diagnosis is therefore 
unimportant. Cancer en cuirasse is more rapidly fatal in 
its course, is at first or soon marked by subcutaneous nodules 
that tend to break down and ulcerate, and is accompanied 
by lancinating pain. 

Treatment. It is doubtful if treatment is ever directly 
of avail. At best, it is unsatisfactory. A general symp- 
tomatic treatment with tonics, good diet, and maintenance 
of the bodily heat is indicated. Galvanism, inunctions of 
the skin with oil, and massage may be tried. West 1 has re- 
ported amelioration in one case by the external use of 
chaulmoogra and olive oil. Graham 2 advises the use of 
anti-rheumatic remedies. Hyde has obtained benefit by the 
use of salt, either moistening it with warm water until it is 
partially dissolved, and then rubbing it briskly over the 
entire surface of the body excepting the face, and then 
washing it off with water of decreasing temperature until 
cold water is used, or a warm tub or sponge bath is taken 
containing one-quarter of a pound of salt to the gallon. I 
have seen one case improved by inunctions of vaseline con- 
taining 10 per cent, of salicylic acid. 

Prognosis. While recovery may take place, it is uncer- 
tain as to its occurrence. Death may result. In children 
the prognosis is more favorable. 

Scleroderma Neonatorum. See Sclerema neonatorum. 

Scleroma Adultorum. See Scleroderma. 

Sclerostenosis. See Scleroderma. 

Scrofulide Boutoneuse Benigne. See Prurigo. 

Scrofulide Crustacee TTlc^reuse. See Tuberculosis cutis. 



1 Trans. Path. Soc. Lond., 1883, xvi. 252. 

2 Journ. Cutan. and Gen.-urin. Dis., 1886, iv. 332. 



460 DISEASES OF THE SKIN. 

Scrofulide Erythemateuse. See Lupus erythematosus. 
Scrofulide Tuberculeuse. See Lupus vulgaris. 

Scrofuloderma (Skro 2 f-u 2 l-o-du 5 rm r -a 3 ). Modern pathol- 
ogy has led, or is leading, us to use the term tubercular as 
synonymous with scrofula, and a number of dermatoses that 
were for many years regarded as scrofulodermata have been 
proven to be due to the bacillus tuberculosis. The most 
brilliant example of this is lupus vulgaris. Many of the 
scrofulides of the French have been shown by more careful 
observation to belong to various other well-recognized forms 
of skin disease. The marks of a scrofulous affection are, 
according to Bazin : 1. The involvement of the deeper layers 
of the skin ; 2. The sharply circumscribed character of the 
lesions ; 3. The absence of pain ; 4. Hypertrophy followed 
by atrophy of the affected parts ; 5. The reddish violaceous 
or livid color of the lesions ; and, 6. Indelible cicatrices left 
by the same. 

In the present condition of our knowledge of the subject, 
and in a book of this sort, it is impossible to do more than 
to place here a few affections of the skin that do not fit in 
under other well-established diseases, while premising our 
remarks by saying that they are either really instances of 
cutaneous tuberculosis, or will eventually be taken out of 
their present position as scrofulodermata. In all of them 
we have, at the same time, that general make-up of the in- 
dividual that long has been recognized as scrofulous. The 
patients are mostly young subjects, flabby of flesh, with 
pasty or doughy complexions, thick upper lips, perhaps with 
clubbed fingers, a marked tendency to chronic catarrhal in- 
flammations of all the mucous membranes, chains of enlarged 
glands in the neck, and perhaps with some old or present 
bone lesions. They are usually dull and apathetic, and are 
prone to die with tubercular lung diseases. 

The most common scrofuloderm is that resulting from a 
suppurating caseous gland, usually of the neck — the scrofu- 
lous ulcer. The gland, before it breaks down, implicates 
the skin over it, and it becomes of violaceous or livid color, 
attached to the underlying parts. By and by, the skin gives 



SCROFULODERMA. 461 

way at one or several points ; the sanious, unhealthy pus 
escapes through the openings ; these enlarge, coalesce with 
others, and so form the characteristic ulcer. This has 
undermined edges ; is of irregular shape ; its base is cov- 
ered with flabby granulations ; it discharges a thin, sanious 
pus; shows little tendency to crusting; is almost painless, 
and heals very slowly, leaving a puckered, disfiguring scar 
that is often bridled. Only one gland may be affected or 
there may be a number of them that enlarge and break 
down. This same form of ulcer may originate from what is 
called a scrofulous gumma, a subcutaneous tubercle inde- 
pendent of the glands, that slowly enlarges to a soft tumor, 
breaks down, and ulcerates. These tumors frequently occur 
on the limbs, and the bones may be involved in the destruc- 
tive processes set up. 

While this is the most common scrofuloderm, we occa- 
sionally meet with two forms described by Duhring — the 
large and the small pustular scrofuloderm. The former has 
"large, rounded, ovalish, or irregularly shaped, yellowish, 
flat pustules, with a deep-red or violaceous areola." This 
begins to crust in the center, and the crust is usually flat 
and scanty, brownish and adherent. Underneath it is an 
ulcer with the characters and course of those just described. 
There may be one, two, or more lesions. The small pus- 
tular scrofuloderm " consists in the formation of pin-head 
and small split-pea-sized, disseminated, yellowish, flat pus- 
tules, with usually a raised, violaceous areola." These crust 
over with depressed yellowish or gray adherent crusts, which 
when removed, or when they fall off, leave depressed, 
punched-out scars resembling variola. Their course is 
very chronic and painless. They occur upon the face 
and extremities of strumous individuals. 

Etiology. The causes of these scrofuloderm ata are 
those of the strumous state, plus infection by the tuber- 
cle bacillus, and need not be gone into here. They are 
most commonly met with in early life. 

Diagnosis. The scrofulous ulcer differs from that of 
lupus vulgaris by an entire absence of the characteristic 
lupus tubercles, and by its history of beginning in a caseous 



462 DISEASES OF THE SKIN. 

gland. Moreover, in lupus we do not have, as a rule, the 
pronounced strumous condition that we have in the scrofulo- 
derm. The pustular scrofuloderms sometimes resemble 
syphilis, but there is an absence of other signs of syphilis, 
and the presence of the strumous state. Moreover, the pus- 
tular syphilide is generally far more disseminated than is 
the scrofuloderm ; its course is far more acute, it yields more 
readily to treatment, and leaves a smoother, less disfiguring 
scar. 

Treatment. The treatment of the ulcers, as well as the 
softening glands, is upon surgical principles. The regula- 
tion of the diet and hygiene of the patient, and the admin- 
istration of cod-liver oil, iron, the compound syrup of the 
hypophosphites, or other tonic, is the most essential part of 
the medicinal treatment. Locally, to the pustular scrofulo- 
derms we may apply iodoform ointment, aristol, or other 
antiseptic powder, or mercurial ointments or lotions. Crocker 
speaks well of chaulmoogra oil emulsion in the dose of ten 
to thirty minims, combined with its external use as an oint- 
ment in the strength of one part to three. 

Scrofuloderma Verrucosum. See Tuberculosis verrucosa 
cutis. . 

Scurvy. See Purpura. 

Sebaceous Cyst. Synonyms : Atheroma ; Steatoma ; 
Wen. 

These innocuous little tumors may occur anywhere on the 
body, but are most common on the scalp, face, neck, and 
back. They vary in size from a millet-seed to an orange. 
They may be rounded, flattened, or hemispherical. There 
will be found in many of them a small opening, out of which 
some of their contents may be pressed. The skin over them 
may be of normal color, pale on account of pressure, or 
red if the cyst becomes inflamed. They may be elastic 
and doughy to the touch, or firm, or soft, according to the 
condition of their contents, which may be fluid and honey- 
like, or cheesy. They tend to grow slowly, and give no 
trouble except by the deformity they cause. In exceptional 



SEBACEOUS CYST. 



463 



cases they may become inflamed and ulcerate. The hair is 
usually absent over them when they occur on the scalp. 
Cysts of similar nature may be found in locations where 
there are no sebaceous glands, and even under the mucous 
membranes. These are called dermoid cysts, and are sup- 
posed to be left over from foetal life. They frequently con- 
tain hair and teeth. 

Fig. 55. 




Sebaceous cysts of scalp. (Hyde.) 



Etiology. Most cysts are due to distention of a seba- 
ceous gland. They occur in both sexes in adult life, being 
rare in children. The origin of dermoid cysts is unde- 
termined. Indeed, considerable uncertainty surrounds the 
pathology of all of them. 

Diagnosis. They must be distinguished from fatty tumors 
and gummata. Fatty tumors are firmer and more doughy 
than cysts, are more often lobulated, occur but seldom on 
the scalp, and are rarely multiple. Gummata are more 
rapid in their growth, attached to the skin, and tend to 
break down and ulcerate. 



464 DISEASES OF THE SKIN. 

Treatment. Complete excision of the tumor, taking 
particular care to remove the whole sac, is the only treat- 
ment to be considered. 

Seborrhagia. See Seborrhcea. 

Seborrhcea (Se 2 b-o 2 r-re r a 3 ). Synonyms : Stearrhea, 
Steatorrhea, Seborrhagia, Fluxus sebaceus, Acne sebacea, 
Pityriasis, Ichthyosis sebacea, Tinea amiantacea seu asbes- 
tina, Eczema seborrhoicum, Lichen circinatus ; (Fr.) Acne 
s6bacee, Acne" fluente ; (Ger.) Schmeerfluss, Gneis ; (Ital.) 
Seborrea. 

A functional disorder of the sebaceous glands, in which 
there is a hypersecretion of sebaceous matter, which may be 
of too fluid or too thick consistence, and forms either an oily 
coating or greasy crusts on the skin. 

Symptoms. Seborrhoea is a functional disease of the 
sebaceous glands, which assumes two forms depending upon 
the quality of the products of the glands. Normally these 
glands secrete only sufficient oil to keep the skin soft and 
supple. This normal oil is not visible to the naked eye. 
Under certain imperfectly understood conditions, the glands 
secrete a too fluid and abundant oil that is readily seen as 
an oleaginous coating of the skin. This form of seborrhcea 
is called seborrhoea oleosa. Under certain other equally 
imperfectly understood conditions, the secretion of these 
glands is not only too abundant, but also too consistent. 
Then the sebaceous matter cakes upon the skin in the form 
of more or less thick plates or masses, and we have the con- 
dition known as seborrhcea sicca. The latter form is denied 
by some authorities, who regard it as a seborrheal dermatitis 
or eczema. 

The most common locations of seborrhea are, naturally, 
those regions where the sebaceous glands are the largest or 
most numerous, namely : the scalp, the chest, the inter- 
scapular region, and the face. 

Seborrhoea oleosa, while it may occupy any or all of these 
regions, is usually subjected to us for treatment only when 
it occurs upon the face. Here it is seen most often on the 
nose, where it forms a greasy coating. At times this is so 



SEBORRHCEA. 465 

slight as to be felt rather than seen, imparting a slippery 
sensation to the finger. At other times it is so abundant 
that it can be seen at a distance as drops or beads of oil, and 
when it is removed with a cloth or blotting-paper it leaves 
an oily stain upon it. When it is wiped off it at once re- 
forms. As the greasy skin catches the dust the face is apt 
to look dirty. At times the skin of the nose may be hyper- 
semic. The forehead is, likewise, a not uncommon site for 
this form of seborrhcea. It may occur on the scalp, and 
render the hair unusually oily. It is most often noticed 
when the patient is bald. It is apt to cause alopecia. Upon 
the nose it may occur as the only disease of the skin. Upon 
the forehead it is not an unusual accompaniment of acne. 
Acne and comedones may complicate the disease in any 
location. 

Seborrhcea sicca occurs with much greater frequency than 
does the oily form of the disense. We are called upon to 
remove it from all the regions already mentioned as the 
locations for the manifestations of seborrhcea. It most 
usually appears in the form of yellowish or grayish fatty 
plates or masses, which when taken and rubbed between the 
fingers impart a greasy feel. Upon the scalp it constitutes 
one form of dandruff. Here it may be general, involving 
the whole scalp, or it may locate itself in certain places in a 
more pronounced way than in others. The hair is dry, and 
after a time, the seborrhcea continuing, it begins to fall, and 
at last baldness is established. 

In this form of seborrhcea the hairy regions are especially 
affected, and we find it in the eyebrows, bearded portions of 
the face, and the hairy portions of the chest. The axillae 
and pubes are rarely affected. In all these places it pre- 
sents similar appearances, yellowish or grayish fatty plates. 
Upon the chest it is not uncommon to see the fatty matter 
in little heaps, piled up as it were about the mouths of the 
hair follicles. Close observation will show that the follicle 
mouths are wider open than they should be. As in the oily 
form, the skin feels greasy, and acne and comedones may 
be present. The interscapular region is frequently affected, 
and both here and on the chest the disease often takes the 



466 DISEASES OF THE SKIN. 

form of round or irregularly shaped patches which look as 
if they were covered with a brownish-yellow varnish. 

Aside from the appearance of the fatty crusts and a slight 
amount of itching when the patient is warm, this form gives 
rise to no symptoms. When the crusts are removed the 
underlying skin is of normal appearance. It may be 
slightly paler than it should be, but it is never moist. 
What the patient complains most about is that the scales 
from the crusts, becoming loosened, fall upon the clothing 
and make it look as if powdered. If the patient happens 
to be bald, he does not find the yellowish fatty crusts upon 
his bald head at all ornamental. But the most serious 
aspect of the case is that if the disease is not cured it is very 
sure to cause the hair to fall, especially if the patient is at 
all predisposed to baldness. 

There is a second variety of seborrhoea sicca, in which a 
varying amount of dermatitis is added to the seborrhoea. 
Then there will be a rim of redness about the fatty crust, 
and when the crust is removed from the skin the underlying 
part will be seen to be red. In this variety there will be 
far more decided itching and burning than in the preceding 
variety. It is to be noted that although the skin is red, it 
is always dry and never infiltrated, in these respects differ- 
ing from eczema. 

Under the name of lichen circinatus and of seborrhea 
corporis (Duhring) has been described the following con- 
dition : Upon the chest and back the eruption will assume 
the form of circular patches covered by a yellowish or 
brownish crust, the peripheries being of a more or less 
bright red. Or the surface of the patch will be smooth and 
appear as if it had been varnished over with a brownish- 
yellow varnish. Sometimes two or more patches run together, 
and then there will be formed an irregularly shaped patch 
with a scalloped border. These patches will assume large 
dimensions in some cases. There may be one or several 
patches upon the chest or back. Instead of these circular 
patches, ring-shaped patches may form. These tend to 
spread at the circumference, and to clear in the center. 
When two rings meet at their peripheries the points of con- 



SEBORRHCEA. 467 

tact give way, and we have irregularly shaped figures with a 
scalloped outline. At times the rings themselves are not 
complete, and we meet with a number of broken rings and 
gyrate lines scattered over the chest or back. Owing to 
the constant rubbing by the clothing to which the chest and 
back are exposed in all people, and to the influence of soap 
and water in those who indulge in the daily bath, the crusts 
are frequently missing from the circles and rings. Then 
the eruption consists of red rings and circular patches, 
which on close inspection are seen to be made up of a num- 
ber of red points. These points are the open mouths of the 
sebaceous glands surrounded by a zone of inflammatory red- 
ness. This variety of seborrhea sicca is met with also on 
the scalp. Indeed it is never present on the trunk without 
at the same time being upon the head. Upon the scalp it 
is seen best in those who are bald. We find at times the 
same rings and circles that we have learned to recognize 
upon the chest, but it is rather more common for the disease 
to assume the form of a more diifused patch involving a 
large part of the scalp, with a zone of redness about the 
edges. When the disease is present in this pronounced 
form upon the scalp it is very prone to pass over on to the 
adjacent parts of the forehead and thus to form as it were 
a corona seborrhoicum. This corona will take the form of 
a yellowish or brownish crust with a red-bounding line. 
The disease may in like manner pass over on to the adja- 
cent parts of the skin of the neck. 

Upon the nose this variety of seborrheal dermatitis forms 
a yellow plate with a red line about it. At times this plate 
may be extensive enough to cover the whole nose. More 
frequently the disease is limited to the furrows behind the 
alae nasi, and then assumes the form of some fatty scales 
upon a good deal of underlying redness. The eyebrows 
and bearded portions of the face are also quite commonly 
affected, but rather as a diffuse redness combined with a 
branny scaling, than as a solid plate surrounded by a red 
line. 

Besides the regions already mentioned as the usual loca- 
tions of seborrhcea, we also meet with the disease upon the 



468 DISEASES OF THE SKIN. 

ears (in the tragus and behind the ears), and in the anal 
fold. The scalp is, however, by far the most frequent loca- 
tion of the disease, and here it may exist alone for years. 
Whenever it exists elsewhere, it is sure to be found at the 
same time upon the head. 

In infants the disease is very common, taking the form of 
thick crusts upon the scalp, that are often of a dirty-gray 
color. These give the careful mother a good deal of annoy- 
ance, she being in great dread lest someone should think 
that she is not careful to keep the precious baby clean. This 
form of the disease is usually the remains of the vernix 
caseosa. 

Pityriasis capitis used to be considered a form of sebor- 
rhea. It should be considered rather as a scaling off of the 
upper part of the corneous layer of the skin, and is consid- 
ered under pityriasis. 

Etiology. The usual etiological factors of seborrhcea, as 
given in the text-books, are debility, chlorosis, constipation, 
and a number of other things, indicating that the condition 
of the patient is below par. Of course, the ability of these 
to cause seborrhcea is questioned ; but that they are quite 
capable of aggravating the disease I have no doubt. The 
disease affects all classes and conditions of men, all ages, 
and both sexes. 

There arc many things that seem to indicate a contagious 
element in the etiology of the disease. Cases have been 
reported in which a husband or wife has contracted dan- 
druff after marriage, he or she having been, before, free from 
the same. Then, those experiments of Lassar and Bishop 
point in the same direction. They took the scales from the 
head of a student who was losing his hair, and, having 
made a pomade of them with vaseline, rubbed the same into 
the back of a guinea-pig, and the pig became bald. Up to 
two years ago we accepted without question the theory that 
seborrhcea was a functional disease of the sebaceous glands. 
But Unna would have us believe that there is no such dis- 
ease as seborrhcea. He teaches that the process is inflam- 
matory from the start, and that the oil that fills the epithe- 
lial scales comes not from the sebaceous glands, but from the 



SEBORBHCEA. 469 

sweat glands. What we have called seborrhoea sicca he 
would have us call, for the present at least, seborrheal 
eczema. (See Eczema seborrhoicum.) He also regards it 
as parasitic. 

In support of his thesis he presents us with microscopical 
studies and certain arguments. His work has been reviewed 
by other competent pathologists, and his observations have 
been substantiated by their findings. His proposition that 
the sebaceous glands are not responsible for seborrhoea has 
not been accepted generally. It has long been known that, 
to a seborrhoea, a dermatitis may be added, and that this, 
under various influences, may become an eczema. But this 
is a very different thing to saying that seborrhoea does not 
exist and that all those cases that we have been accustomed 
to call seborrhoea are but a variety of eczema. 

What we call seborrhoea oleosa, Unna believes to be noth- 
ing more than a hyperidrosis, to which he gives the name 
of hyperidrosis oleosa. This view he must take of necessity, 
on account of his theory of the office of the sweat glands. 

This is an age of micro-organisms, and all diseases are 
traced to a parasitic origin. And so it is affirmed that the 
disease under discussion is due to a micro-organism. Brooke, 
of Manchester, would have us believe that, to the unknown 
parasite of seborrhoea without dermatitis, another equally 
unknown parasite adds itself, to produce the dermatitis and 
the ring formation. For further information the reader is 
referred to the article on eczema seborrhoicum. 

Diagnosis. The diagnosis of seborrhoea sicca is usually 
easy. It is to be recognized by the presence of fatty grayish 
or yellowish plates or crusts, seated either upon a normal or 
slightly reddened skin. These crusts or plates differ from 
those met with in eczema, in being more readily removed, 
and imparting to the finger a greasy feel. Moreover, the 
crusts of eczema are of a more solid consistence, being formed 
by the drying of an almost mucilaginous discharge upon the 
skin. When eczema occurs upon the head the exudation 
glues the hairs together. In seborrhoea, the hairs are not 
glued together, but are dry and powdery. In eczema there 
is more or less itching at all times, while in seborrhoea the 

21 



470 DISEASES OF THE SKIN. 

itching comes on most generally when the head is hot, as 
from artificial lights, sweating, and the like. In eczema 
there is moisture, or a strong tendency thereto. In sebor- 
rhoea moisture is never seen. 

Psoriasis is another disease with which seborrhoea sicca 
is apt to be confounded, as it, too, occurs in the form of pow- 
dery scales and crusts upon the scalp. If a case presents 
itself with these conditions upon the head alone, you may 
be very sure that you have to do with a case of seborrhoea, 
as psoriasis rarely exists upon that region alone. Sebor- 
rhoea usually occurs diffusely, while psoriasis occurs in the 
form of circumscribed patches. The crusts of seborrhoea 
are yellowish or grayish, while those of psoriasis are of a 
silvery hue. In some cases, however, seborrhoea will occur 
in circumscribed patches, and the crusts of psoriasis may be 
of a grayish hue. 

When seborrhoea sicca occurs upon the chest and back in 
the form of rings with scaly centers, we have before us a 
more difficult problem in diagnosis. Now we must decide 
whether we have to do with a seborrhoea, a ringworm, or a 
pityriasis rosea. The resemblance to ringworm is often 
very striking, but ringworm does not, as a rule, occur in so 
diffuse a manner. If, at the same time with the lesion on 
the chest, we find other lesions on the back between the 
shoulder-blades, we may be quite sure that the case is one 
of seborrhoea. Happily in any doubtful case we have a sure 
resort in the microscope. If the case be one of ringworm, 
we will surely find the trichophyton. Upon examining the 
scalp, if the disease be seborrhoea, we will surely find plain 
evidence of it there. There should be no difficulty in recog- 
nizing the presence of a ringworm on the scalp. 

In the differential diagnosis from pityriasis rosea, we are 
deprived of the kindly aid of the microscope. Here, too, 
the occurrence of seborrhoea on the scalp will aid us in our 
decision. Moreover, pityriasis rosea is generally more dif- 
fused over the trunk than in seborrhoea, and occurs also on 
the arms and abdomen. By close inspection we may trace 
the development of the disease from its beginning as a small 
red spot through its successive growth into the typical oval 



SEBORRHCEA. 471 

to annular patch with its withered parchment or chamois 
leather-like looking center. It is scaly, never crusted. In 
some cases, however, the diagnosis will remain somewhat 
doubtful. 

Treatment. The treatment of seborrhcea is simple. It 
is somewhat in favor of the parasitic theory of the origin of 
the disease that the drugs that are most efficacious in its 
cure are active antiparasitics. In my hands by far the 
most satisfactory remedy has been sulphur. After the 
removal of the crusts by means of any oil or grease (this 
should be done the first thing whatever remedy is chosen), 
the sulphur is to be applied in the strength of a drachm to 
the ounce, either suspended in sweet oil, cotton-seed oil, or 
vaseline. It should be well rubbed into the scalp, and the 
application repeated every night for one week. It must be 
remembered that the remedy is to be applied to the scalp and 
not to the hair, and that it is necessary to use only a very 
little of the ointment. After one week's use of the sulphur 
the head is to be washed with soap and water, and the oil, 
or salve, immediately reapplied. During the second week 
it will be sufficient to make the application every other 
night. Thus the treatment is to be continued, the number 
of applications being reduced until they are made but once 
a week. By this time the disease will usually be cured. 
The patient is to be cautioned that relapses are likely to 
occur, and therefore it will be best for him to keep a supply 
of his oil, or salve, on hand so as to attack the trouble as 
soon as it shows itself. 

The objections to sulphur are two: it has a slight odor, 
and it leaves a slight yellow powder on the scalp. The first 
objection is of not much importance and may be overcome 
by the addition of a scent. The second is lessened by 
cautioning the patient not to use the application too freely, 
and by having him wash the head. 

The ointment recommended by my distinguished friend, 
Dr. Bronson, is a very elegant as well as efficient substitute 
for the sulphur. It is 



M. 



R. Hydrarg. ammon., 


9j-ij ; 


5-10 


Hydrarg. chlor. mitis, 


9ij-iv; 


10-20 


Vaselini, 


Ei; 


100 



472 DISEASES OF THE SKIN. 

This is to be used in the same manner as the sulphur oint- 
ment. 

While one or the other of these will bring the case to a 
happy issue, it is well to have a variety of means at com- 
mand. You will find benefit by using salicylic acid in 
castor oil, three per cent, strength ; resorcin in oil or vase- 
line in three to five per cent, strength ; or a solution of 
hydrate of chloral, a drachm to the ounce ; while for a soap 
both for cleansing and stimulation nothing is better than 
the tincture of green soap. If the scalp is peculiarly irri- 
table, then it is best to use a milder soap, such as Pears's 
glycerin soap. 

The treatment of seborrhoea of the body and face is upon 
the same lines as that of the scalp, only that on the body 
we can use an ointment instead of an oil. 

For the seborrhoea of infants usually all that is required 
is to keep the scalp well oiled with olive oil. If this does 
not cure, then a mild sulphur ointment with vaseline may be 
used. 

For seborrhoea oleosa dabbing ether on the part will most 
promptly remove the greasy look. Washing with soap and 
water will act as a stimulant. Powdering with sulphur 
and starch, or using a three per cent, solution of resorcin 
in alcohol and water, will tend to cure. 

In all forms general treatment will be called for if the 
patient is out of tone. General tonic treatment is required 
in nearly all cases of seborrhoea oleosa. 

Under Alopecia furfuracea will be found further direc- 
tions as to the treatment of seborrhoea of the scalp when it 
has led on to baldness. See also Eczema seborrhoicum. 

Seborrhoea Congestiva. See Lupus erythematosus. 

Shingles. See Zoster. 

Siderosis. (Si 2 d-e 2 r-o'si 2 s). A defacement of the skin 
due to the entrance into it of small particles of iron or steel, 
producing blue-black marks. It is seen in iron-workers. 

Sommersprosse. See Lentigo. 

Spargosis. See Elephantiasis. 



SYCOSIS. 473 

Spedalskhed. See Lepra. 

Sphaceloderma. See Dermatitis gangrenosa. 

Spider Cancer. See Telangiectasis. 

Spitzes Condylom. See Verruca and Syphilis. 

Stearrhoea. See Seborrhoea. 

Steatoma. See Sebaceous cyst. 

Steatorrhea. See Seborrhoea. 

Stigmasie. See Stigmata. 

Stigmata. See Haematidrosis. 

Stinkschweiss. See Bromidrosis. 

Stonepock. See Acne. 

Striae et Maculae Atrophicae. See Atrophoderma stria- 
tum et maculatum. 

Strophulus. See Miliaria. 

Strophulus Albidus. See Milium. 

Strophulus Prurigineux (Hardy). See Prurigo. 

Struma. See Scrofuloderma, 

Sudamina. See Miliaria. 

Sudatoria. See Hyperidrosis. 

Sudor Urinosus. See Uridrosis. 

Sueurs Colorees. See Chromidrosis. 

Summer Eruption of Hutchinson. See Hydroa vaccini- 
forme. 

Sweating, Excessive. See Hyperidrosis. 

Sycosis (Sik-o'si 2 s). Synonyms: Sycosis non parastica; 
Sycosis menti ; Sycosis barbae ; Mentagra ; Acne mentagra ; 
Folliculitis barbae ; Folliculitis pilorum ; Herpes pustulosus 
mentagra ; Lichen menti ; Acne sycosis ; (Fr.) Sycosis non 
parasitaire; Dartre pustuleuse mentagre; Adenotrichie ; 
(Ger.) Bartfinne, Bartflechte ; Fikosis ; (Eng.) Barber's itch. 



474 DISEASES OF THE SKIN. 

Definition. An acute or chronic follicular and perifol- 
licular inflammation of the long hairs, chiefly affecting the 
bearded portions of the face ; characterized by an eruption 
of papules, pustules, and tubercles perforated by hairs; by 
the formation of infiltrated patches ; and by a greater or 
less amount of crusting. Sometimes the disease is so intense 
as to form abscesses. 

Symptoms. It is only of comparatively recent years that 
this disease has been recognized as a separate entity, and 
it is still regarded by some authorities as merely a form of 
eczema. The disease begins by the formation of a number 
of red inflammatory papules and tubercles which are more 
or less conical, usually raised above the surface of the skin, 
and always perforated by hairs. Their appearance is pre- 
ceded and accompanied by disagreeable local sensations, 
such as pricking, burning, and smarting, and at times by a 
feeling of tension in the part on account of swelling of the 
skin. In acute cases there is considerable redness of the 
skin between the papules, and the inflammation may be so 
intense as to give rise to enlargement of the neighboring 
lymphatic glands. The papules and tubercles vary in size 
from that of a millet-seed to that of a pea, and are isolated 
or grouped, not every hair follicle in a diseased part being 
affected by the perifollicular inflammation. Only in very 
severe outbreaks or in acute exacerbations do the papules 
and tubercles tend to run together and form infiltrated 
patches. 

The papules and tubercles soon change into pustules, 
which preserve the same characteristics of grouping and are 
likewise always pierced by hairs. These pustules, conical 
in shape, and perforated by hairs, are pathognomonic of the 
disease. In old cases they are met with in the infiltrated 
patches arising apparently without the preceding appear- 
ance of papules and tubercles. The pustules show no tend- 
ency to rupture, but the pus accumulates below, swells up 
alongside of the hair, appears upon the surface of the skin, 
and dries into thin crusts. The amount of crusting is never 
very great, far less than in eczema of the beard, and is 
appreciable mainly when the beard is growing. If the in- 



SYCOSIS. 475 

flammation is very intense, we may meet with small cutaneous 
abscesses here and there instead of pustules. According to 
A. R. Robinson, the amount of pus-production varies with 
the individual attacked, being more rapid and abundant in 
the robust than in the scrofulous ; in acute than in chronic 
cases. 

The hairs, if of any length, are early affected in appearance, 
becoming lustreless. They are at first firmly seated in their 
follicles, and when pulled upon give rise to pain, and if 
extracted their root sheaths will appear as clear glassy 
cylinders. Later, as pus forms more abundantly in the peri- 
follicular tissues, and the follicles themselves are involved 
in the process, the hair becomes loosened and easily 
extracted, when its root sheath will be found swollen with 
pus. If the pus-production is excessive, the hairs will fall of 
themselves or upon the slightest traction. When this occurs 
the hair papillae may be so damaged that no new hairs will 
form. In chronic cases the beard is markedly thinned, 
though permanent loss of hair is the exception. 

The disease may attack any part of the bearded face, and 
may be met with in other hairy regions, as the neck, the 
eyebrows, scalp, axilla, and pubes. But the beard is by far 
most often the site of the disease, the other situations being 
affected in the order in which they are named. Occurring 
in the beard it may be limited to a single region and show 
no tendency to spread. Thus it is met with very frequently 
upon the upper lip alone, or at times upon the chin alone. 
It may attack the whole bearded face in an acute outbreak, 
or it may involve it by extension from a limited area during 
a number of successive outbreaks. In chronic cases it is 
usually symmetrical. The course of the disease is chronic 
and made up of a number of acute exacerbations. If left to 
itself, it may produce a good deal of deformity, the tubercles 
and pustules breaking down, ulcerating and leaving cicatri- 
cial tissue and more or less baldness, though this is excep- 
tional. 

A typical case of sycosis presents the following appear- 
ance : upon a single region, two or more regions, or upon 
the whole bearded portion of the face there will appear 



476 DISEASES OF THE SKIN. 

a number of isolated or grouped papules, tubercles and pus- 
tules pierced by hairs. The skin about the lesions is red- 
dened and swollen, it may be indurated, and there is a 
slight amount of crusting. There is no tendency for the 
disease to spread to non-hairy parts, but very commonly the 
eyebrows will be similarly affected, and a blepharitis will be 
present. When the case is watched for a time marked 
exacerbations will arise often without apparent cause, last 
for a few days, and then the disease will sink into a subacute 
condition. When the disease affects the vibrissa of the 
nose, by extension from the upper lip, the Schneiderian 
membrane becomes swollen and exquisitely sensitive. The 
disease tends to run a chronic course, lasting for years. 

Etiology. The etiology of the disease is not settled. 
It is not very common, perhaps one case in three or four 
hundred. It is non-contagious. It is seen in men almost 
exclusively, as we might expect, as it is the beard that is 
most often affected ; and attacks them most frequently be- 
tween the ages of twenty-five and fifty. It affects all 
classes and conditions. Most of its subjects are in poor 
general condition. 

Eczema is often a forerunner of sycosis, the one process 
passing over into the other. A nasal catarrh is the cause of 
the majority of cases occurring on the upper lip. Shaving 
with a dull razor against a stiff beard is sometimes an excit- 
ing cause, though those who do not shave are by no means 
exempt from the disease. An irritant applied to the skin 
may excite it, such as exposure to intense heat, the dust of a 
workshop, cosmetics, and the like. Exposure to inclement 
weather is regarded by Wilson as the principal cause. One 
of the worst cases I have ever met with was directly trace- 
able to a poultice applied to the face for the relief of a 
neuralgia. Given a hypersemic or irritable condition of the 
skin of the face, arising from any internal or external cause, 
the hairs, especially if they are coarse, may excite the dis- 
ease, acting as irritants when touched or moved. 

Hebra thinks that some cases may be due to an abnor- 
mality in the growth of new hairs. Wertheim ascribed the 
inflammation to irritation of the hair follicle by hairs whose 



SYCOSIS. 



477 



diameter was, relatively, too large for their follicles. By 
many the staphylococcus pyogenes is regarded as the sole 
cause, but this would prove inoperative unless the soil was 
in proper condition for its growth. 

Pathology. The disease is primarily a peri-folliculitis, 
the hair follicles being aifected secondarily, and after them 
the sebaceous glands. 

Diagnosis. The distinguishing characteristic of sycosis 
is the presence of pustules pierced by hairs. It must be 
diagnosed from trichophytosis barbae, eczema barbae, the small 
pustular syphiloderm, acne, and lupus. The differential 
diagnosis of sycosis from trichophytosis barbae is as follows : 



Trichophytosis Barb^. 
Begins as a small scaly spot, a superfi- 
cial ringworm, and gradually in- 
volves the deeper parts of the hair. 

Has its favorite seat upon the chin and 
the submaxillary region ; rarely 
attacks the upper Up. Often sym- 
metrical. 

The eruption consists of tubercles and 
nodules which tend to group, and 
are studded with a number of hairs. 
The internodular portions of the skin 
often remain unaffected. 



Is a deep inflammatory process so 
soon as the hairs become affected 

Hair is diseased primarily, and is 
twisted, split, and broken. May 
readily be removed by slight traction 
and without pain. Its root is often 
dry. 

Subjective symptoms slight, may be 
only slight pruritus. 



Patches of ringworm often present ,'on 
other parts of the body, and some- 
times the disease extends upon the 
neck or face. 

Hairs and scales loaded with the tri- 
chophyton fungus. 

Is a progressive disease, and when 
cured not liable to relapse. 



Sycosis. 

Begins suddenly with an outbreak of 
papules which soon become pus- 
tules, each of which at the start in- 
volves a hair. 

Its favorite seat is the upper lip, and 
sometimes it alone is involved. In- 

. volves the hairy portions of the face 
more generally, and is often sym- 
metrical. 

The eruption consists of papules and 
pustules, each of which is pierced by 
a single hair, and they show no dis- 
position to group. The intervening 
skin is generally reddened, and may 
be diffusedly infiltrated ; and ab- 
scesses may form. 

Is a more superficial inflammation. 

Hair diseased secondarily, and comes 
away at first with difficulty, causing 
much pain. Later is easily removed 
and its root is swollen with pus. 

Subjective symptoms of pricking, 
burning, and tension of the part. 
These are often intense and attended 
by swelling of the face. 

Limited in most cases to hairy parts of 
face. No tendency to extend on non- 
hairy parts of face or neck. 

No fungus present. 

The course of the disease made up of a 
number of acute outbreaks. Liable 
to relapse. 



The differential diagnosis from eczema of the beard can- 
not be made with so much certitude, and often we must 
remain for a while in doubt as to the true nature of the case. 
At times sycosis is left by a preceding eczema, and we may 

21* 



478 DISEASES OF THE SKIN. 

meet with a case in the transition -stage when a sure diag- 
nosis would, manifestly, be impossible. A typical case of 
pustular eczema is attended by a far greater amount of 
crusting than is sycosis, and the crust is of a more greenish 
or blackish color. Upon removing the crust in eczema a 
moist and oozing surface will be exposed, while in sycosis 
we will do no more than remove the tops from a number of 
pustules. In eczema the pustules break down more readily 
than in sycosis, and they are not so accurately located about 
the hairs. In eczema the whole surface of the skin is in- 
volved, and the process tends to extend upon non-hairy 
parts of the face. While exceptionally eczema is confined 
to the hairy portion of the face, this is always so in sycosis. 
The duration of the disease will at times help us to a diag- 
nosis, sycosis being far more chronic than is eczema. In 
syphilis, when the beard is involved, we will find pustules 
upon other portions of the body, and the history will help 
us to a correct conclusion. Further, the pustules or papules 
of syphilis are grouped in circles and segments of circles, are 
of a peculiar color, and their development is painless and 
comparatively slow. Acne is scattered about the whole face, 
and is usually met with in young persons. Comedones are 
present, and its papules, pustules, or tubercles have no defi- 
nite relation to the hair. The course and history of lupus 
are so different from those of sycosis that it is hardly possible 
for them to be confused. In lupus vulgaris we have the 
characteristic brown tubercles, which do not contain pus, are 
not confined to the hairy portions of the face, generally 
begin in early life, and tend to ulcerate or to be absorbed 
and leave behind cicatrices. 

Treatment. The treatment of sycosis is both general 
and local. While many cases will yield to local treatment 
alone, there are quite as many, if not more, which require 
general treatment. The surroundings of the patient must 
be inquired into, and his mode of life, and we should en- 
deavor to put him in as good a hygienic condition as possi- 
ble. He should be advised against exposing himself to dust 
and wind, and then only with his face powdered or protected 
with ointment, and even against smoking, especially in a 



SYCOSIS. 479 

wind where the smoke blows against the face. The proper 
regulation of the diet is important. Many cases will improve 
if we stop their tea, coffee, hot drinks of all sorts, ale, beer, 
and spirits. If the digestive process seems at all embar- 
rassed, it is well to put the patient on a light diet for morn- 
ing and evening, and direct him to take his principal meal 
at noon, eating meat only at that time. Anything that is 
known to him to be indigestible must, of course, be pro- 
hibited. In a word, the diet and hygiene of the patient 
should be regulated. 

What medicines we should administer will depend upon 
the stage of the disease. In the acute stage, when there are 
much swelling and inflammation, a good dose of blue pill, 
calomel, or some other active cathartic is to be ordered, to 
be followed by an alkaline diuretic. When pustulation is 
active the sulphide of calcium or calx sulphurata may do 
good. Piffard recommends this very highly, giving one- 
tenth of a grain two or three times a day. 

Small doses of calomel, of one-tenth of a grain, three 
times a day, for two or three days at a time, are useful in 
relieving the congestion of the skin. In chronic cases iron, 
cod-liver oil, and other tonics are indicated if there is a 
state of debility. Arsenic is advised in very obstinate cases. 
If indigestion is present, we must address our remedies to 
its relief before we give calcium, arsenic, or other remedy 
for the disease proper, and then will probably have no need 
of so-called specifics. 

The local treatment must vary with the condition found, 
whether it be acute or subacute. When the disease attacks 
the upper lip the nose must be examined for evidences of 
catarrh, and that condition treated if found. 

In the management of an acute case of sycosis soothing 
remedies are needed. Hot water should be sopped on the 
part for some five or ten minutes once or twice a day, and 
this should be followed, if the beard is growing, by the use 
of a simple oil, such as olive oil or sweet almond oil ; or if 
the face is shaved, the zinc oxide ointment or cold cream 
may be used ; or better still, Lassar's paste, as follows : 



480 DISEASES OF THE SKIN. 

R. Amyli, \ aa ... g 

Zinci oxidi, J ° J ' 

Vaselini, ad ^j ; 32 



M. 



Powdering the part with cornstarch, or bismuth and talc, 
after smearing on a little vaseline, will at times give ease 
and comfort. 

In the early stage, if the inflammatory symptoms are 
not very intense, a mild white precipitate ointment will 
sometimes check the disease. Duhring recommends bath- 
ing tne face with " black wash," followed by zinc oxide 
ointment with a drachm of alcohol or half a drachm of cam- 
phor to the ounce, spread on cloths and bound on j and 
speaks well of the oxide of zinc ointment with fifteen to 
thirty grains of calomel to the ounce. 

When the disease has reached the pustular stage, and 
there is more or less crusting, the crusts are to be removed 
by the free use of olive oil, or oil of sweet almonds with two 
per cent, of salicylic acid, letting it soak in thoroughly over 
night and washing the part with soap and warm water the 
next morning. If the crusts are thick, it is a good plan to 
tie up the bearded face in a towel after anointing it with oil. 
After the crusts are gotten rid of, the hairs should be pulled 
out of the pustules and epilation continued until pustules 
cease to form. The patient must be made to understand 
that epilation is necessary both for the cure of the affection 
and the salvation of the hair. After epilating, the oxide 
of zinc ointment, Lassar's paste, or diachylon ointment is 
to be used. Shaving is recommended, but it seems to me 
better to content ourselves with cutting the hair short. 
Shaving is apt to irritate the skin, and certainly would favor 
the dissemination of the pus organisms. Sulphur in the 
form of an ointment, half a drachm to a drachm to the 
ounce, or in powder, will sometimes do good, but often will 
prove too irritating. Tilbury Fox recommends the use of 
the following ointment after epilating : 



R. Zinc oxide, 1 ... . 4 

Zinc carbonate, / ^ J ' 

Rose ointment, ad J j ; 32 



M. 



SYCOSIS. 481 

Instead of an ointment we may use oxide of zinc, one 
drachm to the ounce of linseed or other oil. Shoemaker 
advises the application of equal parts of oleate of mercury 
and olive oil. 

In subacute and chronic cases a more active treatment is 
necessary. Here our aim is not so much to allay inflamma- 
tion as to stimulate the skin. To this end we may use the 
soap and salve treatment of Hebra, which renders such good 
service in chronic cases of eczema. (See page 178.) In 
some cases better results will be attained by the use of dia- 
chylon ointment, or Lassar's paste with ten or fifteen grains 
of salicylic acid to the ounce. In very obstinate cases where 
there is much thickening of the skin green soap may be 
kept applied to the part like an ointment. When sufficient 
inflammatory reaction is produced emollient measures, as in 
the acute stage, should be used. 

Our success in treating these cases will vary with the 
thoroughness with which the dressings are applied. All 
ointments must be spread on cloths, not on the skin, and the 
dressings must be kept continuously in close contact with the 
affected part. Sometimes a sulphur ointment, one-half a 
drachm to two drachms to the ounce ; an ointment of iodide 
of sulphur ; the ointment of the ammoniate (gr. xv-xxx ad 
Sj) ? or the nitrate (5j-ij ad 5j), or the red oxide (gr. v-xv 
ad Sj) of mercury will prove useful. Robinson recommends 
the following ointment : 

R. Ungt. diachyli (Hebra), 1 ~ z- 50 

Ungt. zinci oxidi, / cc dJ ' ' 

Ungt. hydrarg. ammon., ,^iij ; 10 

Bismuth, subnitrat., 3J SS ; 5 M. 

He has found cod-liver oil the best local application in 
strumous subjects. 

Behrend has obtained good results by scraping the affected 
parts with the dermal curette and dressing with a simple 
ointment or oil. All abscesses must be opened. In some 
cases the following ointment has given me satisfaction after 
other combinations have failed : 



482 DISEASES OF THE SKIN. 



R. Hydrarg. sulph. rubri, 




Sulph. sublimat., 


12 


Adipis, 


ad 50 


01. bergamot, 


q. s. 


To be kept on constantly. 





M. 



Solutions of the bichloride of mercury, 1 in 1000 ; or of 
resorcin in alcohol 5 per cent, strength, after shaving, may 
be used. 

Kaposi recommends the following : 

R. /3-naphthol., 1 

Spt. sapo. viridis, 25 

Alcoholis, 50 
Bals. peru v., 2 

Sulph. loti, 10 M. 

Boric acid, salicylic acid, and numerous other remedies 
seem to do good in some cases. To assure against a relapse 
it is necessary to continue making applications to the skin 
for four or five months after apparent recovery. 

Prognosis. This is one of the most obstinate of diseases. 
Left to itself, when once under headway it shows no ten- 
dency to get well, and has been known to last twenty or 
thirty years. Even under the most judicious treatment it is 
an obstinate disease, taking weeks or months before a cure is 
effected. Relapses are exceedingly liable to occur, and these 
sometimes show a disposition to recur at certain seasons. 
Unless the hair is carefully plucked from the inflamed folli- 
cles permanent baldness may be caused. But the disease is 
not dangerous to life, and it is curable. 

Sycosis Contagiosa. See Trichophytosis barbae. 

Sycosis Framboesia. See Dermatitis papillaris capillitii. 

Sycosis Parasitica. See Trichophytosis barbae. 

Syphilis 1 (Si 2 fi 2 l-i 2 s). Synonyms : Malum venereum ; 

1 In the description of the syphilides I have followed very closely 
those given by Prof. G. H. Fox in his Photographic Illustrations of 
Skin Diseases, Treat, N. Y. ; and by Prof. E,. W. Taylor in his Pathology 
and Treatment of Venereal Diseases, Lea Brothers & Co., Philadelphia, 
1895. To both of these gentlemen I would extend my grateful thanks 



SYPHILIS. 483 

Lues; Morbus Gallicus, seu Italicus, seu Hispanicus, seu 
Neapolitanus, seu Indicus ; (Fr.) Yerole, or Grosse verole ; 
(Ger.) Lustseuche ; (Eng.) Bad disorder, Pox. 

Whole books have been written upon this disease. Here 
we can give only a brief outline of the disease, and that as 
it affects the skin alone. For a further account of the dis- 
ease the reader should consult the larger special treatises. 

Symptoms. Syphilis may be acquired or hereditary. 
It is acquired by local infection, the first manifestation of 
which is the appearance of the initial lesion, commonly 
called the chancre or hard sore. In probably ninety per 
cent, of the cases this initial lesion is located on the geni- 
tals, and in the vast majority of these its site in males is the 
glans and prepuce. But the initial lesion may be found on 
any part of the body, and within the mucous cavities. Ac- 
cording to a table of one hundred and ninety-eight extra- 
genital lesions compiled by Pospelow, 1 the female breasts 
were affected in sixty-nine cases; the lips in forty-nine 
cases ; the throat in forty-six cases ; and then in very much 
less frequency the gums, tongue, chin, eyelids, nose, trunk, 
anus, arms, and legs. Some obscure cases of syphilis are 
due to the initial lesion being in the urethra or upon the 
cervix uteri and thus having escaped detection. 

The initial lesion appears within two to six weeks after 
inoculation with the syphilitic poison ; usually the interval 
is less than four weeks ; exceptionally it may be ten weeks. 
This is the period of incubation. Opinions are divided as 
to whether the initial lesion is a purely localized lesion, or 
the expression of a general constitutional infection that first 
declares itself at the point of inoculation. It appears to me 
that the weight of the argument is altogether on the side of 
the last opinion. The initial lesion may assume the form of 
a scaly patch, a dry or moist papule, a superficial erosion, or 
a circumscribed ulcer with perpendicular edge. Induration 
of the base is a characteristic of all forms of initial lesion ; 

for the permission to use their books that was so graciously granted 
to me. 

1 Arch. f. Dermat. u. Syph., 1889, xxi. 59. 



484 DISEASES OF THE SKIN. 

it is sharply defined and imparts to the fingers a distinct re- 
sistance that may be as firm as cartilage. Commonly it 
is parchment-like. To detect it, the lesion must be gently 
pinched between the thumb and finger. It is present coin- 
cidently with the appearance of the initial lesion or within 
a few days afterward. It remains for a long time after the 
disappearance of the lesion — for two or three months or 
longer. The secretion from the initial lesion, when present, 
is thin and chiefly serous. The duration of the lesion is 
variable ; it may disappear before the outbreak of cutaneous 
symptoms, but very often remains for some time after this 
event. Unless there has been ulceration, no cicatrix will be 
left. It may leave a staining of the skin or an induration. 
It is usually a solitary lesion, though it may be multiple. 
Enlargement of the nearest lymphatic glands accompanies 
the initial lesion. If on the external genitals, it will be those 
of one or both groins. They become hard, and are painless 
and freely movable. Suppuration is rare, and probably the 
result of mixed infection. A pleiad of glands, three arranged 
in a triangle, is quite characteristic of syphilitic infection. 
In women initial lesions are often so small and last so short 
a time that they are not noticed. In them induration is 
often not noticeable, and the diagnosis is much more difficult 
than in men. They are found on the external genitals, 
within the vagina, and on the cervix uteri. 

The initial lesion may at first assume the character of the 
soft sore. This is the result of mixed infection with both the 
virus of syphilis and the local venereal ulcer. The ulcer 
will after a while become indurated and assume its proper 
characteristics. It is in these cases that a suppurating 
adentitis may develop. Modifications from location of the 
initial lesion must also be noted. 1. Of the urethra. 
These may be at the meatus, in the fossa navicularis, or 
deeper parts. Those at the meatus attract attention by 
causing a slight impediment to urination. The lips are 
found glued together by a scanty, viscid secretion. The 
normal opening of the urethra becomes lessened by the 
induration which usually involves the entire circumference 
of the meatus. Those deeper down may give rise not only 



SYPHILIS. 485 

to interference with urination, but also to some pain, and 
later to a muco-purulent or purulent discharge like that of 
gonorrhoea, because they cause a urethritis. They may 
be felt as a hard, tender, circumscribed nodule, and be 
seen, with the endoscope, as a grayish-red erosion of the 
urethral wall. They may give rise to symptoms of stric- 
ture. 2. Of the anus. These may be without the anus, 
at its margin, or within the anal ring, and usually present a 
thickened, fissured, ulcerated surface. They are of a pale 
rose tint, and decidedly indurated. 3. Of the fingers. 1 
They may be seated at any part of the phalanges, but most 
often are at the sides or base of the nail, or at its free mar- 
gin. They begin as a papule, pustule, excoriation or 
fissure, and attract attention as an obstinate hang-nail or 
fissure, and we find an irregular, deep-red, somewhat elevated 
mass that is ulcerated and covered with a scanty, serous 
secretion. The finger is apt to be swollen at its end. The 
epitrochlear and axillary ganglia are enlarged, and there 
may be moderate lymphangitis. 4. Of the lips. They are 
usually covered with a greenish-brown crust, which, when 
removed, leaves either an erosion of little, if any, hardness, 
or an ulceration of cartilaginous consistence. The lips may 
be greatly swollen. They may begin as a fissure or 
painful excoriation. The lips are nearly equally affected, 
but usually only one. The submaxillary glands on the side 
of the lesion are usually first affected. 5. Of the tongue. 
Here we meet with hard circumscribed, flat, slightly 
elevated, dull red, smooth, pea-size nodules ; or a round, 
sharply defined, fleshy red, raised, hard ulcer. The cervi- 
cal and submaxillary glands are enlarged. 6. Of the throat. 
The patient first notices difficulty or pain in swallowing, 
the latter in the region of the tonsils. Then the submax- 
illary and cervical glands become swollen. Examination 
shows an intense, limited or diffused, general or unilateral, 
brown or dark redness of the pharynx. The tonsils are en- 
larged, hard, and red, and may be eroded, and perhaps 

1 An admirable study of these lesions by Dr. R. W. Taylor will be 
found in the Medical Record, 1891, xxxix. 69. 



486 DISEASES OF THE SKIN. 

covered with an ash-colored deposit, a false membrane. Or 
we may find an irregular, hard ulcer with gnawed-out 
edges, and, may be, crater-shaped floor covered with dirty- 
brown or grayish deposit. One or both tonsils may be 
affected. 7. Of the nipple. These are usually multiple, 
and may take the form of an erosion, a scaly patch, or an 
indurated fissure. The size varies from that of a lentil up 
even to three inches in diameter. They are sometimes linear, 
sometimes sickle- shaped along one side of the nipple, and 
sometimes completely encircling the nipple. The nipple is 
red, or dark red, enlarged, hardened, and at times flattened. 
Mastitis may complicate matters. The axillary glands are 
enlarged, as are often those along the upper edge of the pec- 
toralis major. On healing, the initial lesion leaves a flat- 
tening of the nipple, and perhaps a leaning of it to one side, 
characteristics that should put us on our guard in the ex- 
amination of wet nurses. 

About six weeks after the appearance of the initial lesion 
(it maybe as early as the twenty-fifth day, or as late as the 
one hundreth and sixtieth), we have the stage of eruption of 
the so-called secondary syphilides. Usually, just before the 
outbreak of the eruption, or shortly after it, examination will 
show a general enlargement of the lymphatic glands, espe- 
cially the epitrochlear and post-cervical. At the time of 
the eruption, or shortly before, the patient will experience 
certain constitutional disturbances such as severe headache, 
malaise, pains in the joints, and a rise of temperature of 
moderate extent. In very many cases these disturbances 
either do not exist, or are of so slight severity as not to 
attract the patient's notice. In some cases a more or less 
profound anaemia will manifest itself, or the patient will fall 
into a markedly cachectic condition. Either of these may 
last far into the secondary period of the disease. Weakly 
individuals are more prone to these severe constitutional de- 
rangements than are the robust, and Fournier teaches that 
they are most apt to appear in women. 

The eruptions of syphilis are, for convenience, divided 
into two groups named, respectively, secondary syphilides 
and tertiary syphilides ; or the early and late lesions. No 



SYPHILIS. 487 

hard and fast lines can be drawn, as sometimes those lesions 
usually seen late in the disease manifest themselves early in 
its course. The secondary syphilides are those that develop 
during the first two years after infection. They are marked 
by a more or less general and symmetrical dissemination 
over the whole cutaneous surface; by polymorphism; by 
running a rather definite course; by implicating the more 
superficial parts of the skin and mucous membranes ; and 
by leaving little, if any, trace of themselves. In these re- 
spects they differ from the lesions of late syphilis, which 
are grouped and limited to certain regions ; are not poly- 
morphic ; show less tendency to run a definite course, in- 
volve the deeper structures, and are prone to leave perma- 
nent scars. 

The eruptions of secondary syphilis are the erythematous, 
the papular, and the pustular syphilide. The first eruption 
of the secondary stage is usually an erythematous one, the 
macular syphilids, or the syphilitic roseola. Unlike other 
syphilides, which are all largely composed of new cell-growth, 
this may be a hyperemia without cell-infiltration. It may be 
a general eruption, though generally most marked upon the 
trunk and flexor aspects of the limbs. The macules are 
about the size of a ten-cent piece, or smaller, of a faint rose- 
red color, circular in form, and little, if at all, raised above 
the skin. At times we meet with annular lesions from dis- 
appearance of the center of the macule. The lesions, ex- 
cepting in relapsing eruptions, are distinct from each other. 
They become more evident on exposure to cold, it being no 
uncommon thing to see them appear upon the patient's body 
while he is before us stripped for examination. After being 
out for a time their color becomes purplish-red, changing to 
a tawny or yellowish-red, and later to a brownish-yellow. 
In their early stage they can be made to disappear on pres- 
sure. They either disappear, and leave either no trace or 
some pigmentation, or they develop into papules. They 
often coexist with papules and pustules. Their evolution 
usually requires a week or ten days ; sometimes it may ap- 
pear very rapidly. It runs a course of one or three months 



488 DISEASES OF THE SKIN. 

if not removed by treatment. Relapses occasionally occur, 
and these may be met with as late as the end of the first 
year. Then it is usually limited to certain regions. It gives 
rise to no inconvenience, and is often overlooked by the pa- 
tient except when it appears on the face or hands. At this 
time there is apt to be an erythematous condition of the 
pharynx, some sore-throat, a rheumatoid affection of the 
joints, falling of the hair, and, perhaps, an iritis, and mu- 
cous patches in the mouth, upon the vulva, in the groin, 
upon the scrotum and under surface of the penis, and about 
the anus. 

While the diagnosis is easy, if we have seen the patient 
from the time of the initial lesion, in some cases we must 
differentiate between it and mottling of the skin ; an ex- 
anthem ; a medicinal eruption ; chromophytosis ; and, if we 
have annular macules, trichophytosis corporis. From mot- 
tling of the skin it is diagnosed by the fact that in syphilis 
we have macules of a reddish tint, interspersed with skin of 
normal hue, while in mottling we have light macules with 
dull purplish-red interspaces. From an exanthematous fever 
it is diagnosed by the absence of catarrhal or gastric symp- 
toms, and marked pyrexia, and by the sluggish character of 
its lesions. From a medicinal eruption it is diagnosed by 
an absence of high fever and gastric disturbance, and by its 
lesions lacking the urticarial or cedematous character. From 
chromophytosis it differs in having a red rather than a caf§- 
au lait color, by not being scaly nor capable of removal by 
scraping, by its more extensive distribution, and by the ab- 
sence of the microsporon furfur from the scales when they 
are examined under the microscope. From trichophytosis 
it differs in the greater extent of its distribution, and the 
absence of the trichophyton fungus from scales scraped 
from the skin. From pityriasis rosea the differentiation is 
sometimes difficult when the syphilitic macules have assumed 
a ring-form. As a rule, there is no difficulty, as a pityriasis 
rosea will be scaly, and will present not only rings, but mac- 
ules of all sizes, while the syphilitic macules are not scaly 
and are of more uniform size. 

The papular syphilide, while usually following the ery- 



SYPHILIS. 489 

thematous syphilide, may be the first eruption of the disease. 
Indeed a great many cases begin as a maculo-papular erup- 
tion. The papules may develop from macules, or may appear 
as papules. Very commonly both macules and papules will 
be present at the same time. If it follows the macular 
form, it is apt to appear while the latter is fading. The 
eruption consists of a greater or less number of firm, 
rounded, fleshy red elevations of the skin varying in size 
from a pin's head to one inch in diameter. After continu- 
ing unchanged for a certain time they undergo absorption ; 
the oldest or central part of the papule disappears first, sinks 
in a little, and becomes scaly. It is then that slight pruri- 
tus may be complained of. They are scattered over the 
whole cutaneous surface, and often appear in well-marked 
groups. They are prone to relapses, and sometimes are 
seen as a relapsing eruption in the tertiary stage of the dis- 
ease, when they do not occur as a general eruption, but in 
groups upon one or more regions of the body. According 
to their size, they have received the names of the lenticular 
and miliary papular syphilide, the former being the larger 
and most common eruption. 

The lenticular papular syphilide has hemispherical or 
flattened lesions forming firm, fleshy, lentil to split-pea-sized 
prominences with a smooth and glossy surface. Not infre- 
quently the superficial layer of epidermis over them is want- 
ing from the central portion, and slightly detached around 
the base, forming a fringe called the collarette of Biett. 
This is regarded as a diagnostic symptom. The color of 
the papules is at first light red ; later it assumes a raw-ham 
color that is best seen on the legs. From the knee down 
they may have a purplish or hemorrhagic appearance. They 
are usually present in great number and scattered over the 
whole body. On the face they are apt to locate along the 
hair-line on the forehead, forming the corona veneris. On 
the scalp they are not very numerous, and are apt to become 
papulo-pustules and crust ; or they itch slightly and are 
scratched. The palms and soles are usually well covered in 
any general outbreak of them. Here they appear as red- 
dish spots under the thick epidermis. Desquamation is often 



490 DISEASES OF THE SKIN. 

seen over the papules in the palms and soles. Sometimes 
the eruption is very slight in extent, only a few scattered 
papules being found. This syphilide develops slowly, runs 
a course of one or two months, and disappears, leaving pig- 
mentation or slightly depressed spots, both of which are not 
permanent In undergoing resolution they may become 
scaly and form a papulo-squamous syphilide, or pustules 
may form on them during their course, and we then have 
the papulo-pustular syphilide. 

Fig. 56. 





Scaling papular syphilide. (After Lassar.) 

While the form of lenticular syphilide just described is 
the typical one, we see at times larger papules, from three- 
eighths to half an inch in diameter, forming the large, flat 
papular syphilide. This rarely, if ever, is a general 
eruption, but is limited to certain regions. It may occur 
alone or with the lenticular syphilide. It usually follows 



SYPHILIS. 491 

the latter or appears when it is fading. It frequently comes 
as a relapsing syphilide, and often appears late in the second 
year. It has a flattened surface and a circular outline. The 
lesions often coalesce and form patches which frequently 
become scaly and resemble psoriasis. The scaling is never 
very great ; the scales are thin and adherent, and do not 
cover the whole patch. They frequently occur upon the 
flexor aspect of the extremities, and in the bends of the 
joints. Instead of forming patches by coalescence the indi- 
vidual papule may enlarge at the circumference and become 
depressed at the center and form circinate lesions, whose 
surface may become moist. 

Fig. 57. 




Condylomata lata. (After Taylor.) 

The moist papule or mucous patch is a modified form 
of the lenticular papule, and is simply a papule subject to 
heat and moisture. They are found where two folds of 
skin rub together, as in the peno-scrotal fold, between the 
scrotum and inside of the thigh, around the anus and vulva, 
and upon mucous membranes. They are of circular shape 
and have a flattened surface which is sometimes depressed 
in the center. Fresh ones have a bright-red or raw appear- 
ance, but they soon become covered with a dirty whitish 
coating made up of thickened and softened epidermis. About 
the anus and vulva they form large flattened tubercles called 
condylomata lata. (Fig. 57.) They give forth a most 



492 DISEASES OF THE SKIN. 

sickening odor when not kept clean. When in the mouth 
they form "opaline patches," looking as if the mucous mem- 
brane had been pencilled with nitrate of silver. They are 
usually not elevated. If at the angle of the mouth, they are 
generally fissured. The mucous patch is one of the most 
contagious of syphilitic lesions, the evidence of infection 
being an initial lesion of syphilis, and not a mucous patch. 

The miliary papular syphilide is much rarer than the 
other form of papular syphilide ; in fact, it is one of the 
least common of the syphilides. It consists of numerous 
pin-head or slightly larger sized conical papules of a 
purplish-red hue, either disseminated over the whole body 
or aggregated in groups forming circles or segments of circles. 
They are developed about the hair follicles and have de- 
pressed centers. Many of them may be surmounted by 
a small vesicle or vesico-pustule. This constitutes what has 
been named the vesicular syphilide. Sometimes the lesions 
when closely pressed into patches may be scaly. It may be 
an early lesion or a relapsing later one. In the latter case 
the eruption is not abundant, but in groups. The color is 
brownish-red, and pigmentation and permanent pitting are 
left by the lesions, if they have lasted any time. They rarely 
change into condylomata. Their evolution is rapid, being 
fully developed within two weeks. Pea-sized conical papules 
sometimes are seen among the miliary ones. 

The diagnosis of the papular forms of syphilis is gener- 
ally easy because other symptoms of the disease will be 
sure to be present and to establish the diagnosis. It is 
possible that error may arise in distinguishing the patches 
of scaling papules from psoriasis, but here the location of 
the patches upon the flexor surfaces of the extremities, and 
over the bends of the elbows ; the* scaling not being com- 
mensurate with the patch, but having a red, sharply defined 
border about it; and the well-marked infiltration of the 
patches are all features that would throw out the diagnosis 
of psoriasis. The miliary papular syphilide may be con- 
founded with lichen planus or keratosis pilaris, but the 
absence of itching is always in favor of a syphilide, and the 
conical or rounded shape of its papules is in strong contrast 



SYPHILIS. 493 

with the flat, angular, and umbilicated papule of lichen 
planus. The syphilide is also a much more widely dissemi- 
nated eruption than is lichen planus or keratosis pilaris 
likely to be. 

The pustular syphilide is the last eruption belonging to 
the secondary stage that remains to be described. It is 
always evidence of a poor condition of the health of the 
patient who bears it. It may be the first eruption of syph- 
ilis, or follow the erythematous or papular form, or occur 
later. It may develop from a macular or papular syphi- 
lide, or occur with either of them. It may occur as a re- 
lapsing eruption late in the tertiary period. It is held by 
some authorities that it is always the product of infection of 
a syphilide by pus-organisms. The appearance of this form 
of syphilide is not infrequently accompanied by fever. It 
may assume varying forms and sizes to which in the faulty 
nomenclature of the older writers have been given the 
names of non specific lesions, greatly to the confusion of the 
student. Professor George H. Fox has done well in dis- 
carding all such terms, and in describing two forms, the 
lenticular and miliary pustular syphilide. 

The lenticular pustular syphilide (variola- form) occurs as 
a disseminated eruption of small, hemispherical, pea-sized 
pustules, having a hard, papular base and more or less of 
an inflamed areola. It may develop by the softening up of 
a papule, or be a papulo-pustule from the start. In the 
latter case its outbreak will be marked by fever, which is 
apt to recur with each succeeding outbreak. The eruption 
may be general, or upon certain regions. The lesions are 
discrete, and do not form marked groups, although in the 
pustular eruptions, as in others, it is easy for one who looks 
for them to find groupings in circles and segments of circles. 
A few days after they appear they begin to desiccate, and 
the larger ones may umbilicate. At this stage they become 
crusted with a dirty-yellow, brownish or greenish-brown 
crust. This falls soon and leaves a transient pitting and 
pigmentation. Relapses may occur. 

The miliai^y pustular syphilide (acne form). This erup- 
tion consists of millet-seed to pin-head-size acuminate pus- 

22 



494 DISEASES OF THE SKIN. 

tules developing generally from papules and occurring in 
small groups of about the size of a quarter- or half-dollar. 
It may occur as a general eruption, but is apt to be more 
marked and lasting on the extremities than on the trunk. 
The lesions, especially when occurring upon the flexor 
aspect of the joints, are liable to coalesce. They are de- 
veloped in and around the hair follicles, and may be per- 
forated by hairs. They are topped with small crusts. The 
eruption lasts two or three months by the outbreak of new 
lesions, unless controlled by treatment. They leave pig- 
mentation and pitting that may remain for several months. 

While these are the two chief varieties of the early pus- 
tular syphilide, there is another variety that is called the 
impetigo-form syphilide, and occurs most commonly in the 
middle or latter part of the first year of syphilis. It may 
occur as late as in the third year. In it the pustules are 
small and flat, and by confluence an impetiginous crust is 
produced. They may form patches with crusting only at 
the border. This form is met with usually on the face, arms, 
and thighs. A few superficial ecthymatous lesions may 
develop, but ecthymatous lesions are usually late manifesta- 
tions. 

The diagnosis of the pustular syphilide is usually easy 
from the presence of other symptoms of the disease. The 
lenticular form may be mistaken for variola or varioloid. 
It differs from these in the infiltrated bases of the pustules, 
in being composed of lesions of varying size and age, in not 
occurring in the mouth, and in not running a definite rapid 
course. The miliary form might be mistaken for acne, but 
it is never confined to the face, chest, and back as is acne, 
nor does it present comedones, and so great multiformity of 
lesions. 

Tertiary Syphilides. The erythematous, papular, and 
pustular syphilides are those eruptions that occur in the 
early months of syphilis and during the first year. As we 
have seen, they may also constitute relapsing eruptions later 
in the disease. Modifications of them may occur late in the 
secondary period or even in the tertiary period. Besides 



SYPHILIS. 



495 



these, we have a second group of syphilides that occur any 
time after the first year, and sometimes as late as twenty or 
more years after the initial lesion, when the patient may 
have lost all remembrance of it. To these eruptions the 
name of tertiary or late syphilides is given. Their peculiari- 
ties have been indicated in a general way when writing of 



Fig. 58. 




Annular tubercu!ar|syphilide. (AfterjTAYLOR.) 

the early syphilides. They are the tubercular, the squa- 
mous, the pustulocrustaceous, the gummatous, and the 
ulcerative syphilides. Exceptionally these eruptions may 
occur before the second year, when they are to be regarded 
as precocious lesions. 



496 DISEASES OF THE SKIN. 

The tubercular syphilide occurs in the latter part of the 
second year of syphilis, or later. Exceptionally it may 
occur during the first year as a so-called precocious syph- 
ilide. As a rule, the early syphilides cease appearing after 
six or seven months, and then after a varying interval 
of rest the late lesions appear. These may never come 
at all, usually as the result of judicious treatment, or it 
may be because of the vigorous resistance of the consti- 
tution of the individual. Tubercular lesions occur in 
the form of clustered nodules in the deeper part of the 
corium. At first they are of faint red color; gradually 
they become a dull red, and later still darker. In size 
they vary from that of a split-pea to that of a hazelnut, 
and constitute firm, elastic, fleshy protuberances. They 
are round, smooth, and somewhat glossy, or flat, rugous, 
and withered. They are frequently scaly. Most often they 
are arranged in circles or segments of circles; or they may 
be in the form of rings from the first, or in consequence of 
the disappearance of the central members of the group. 
(Fig. 58.) There may be but a single group; or numerous 
groups may be scattered over the body in a symmetrical 
manner. A very frequent location for them is the posterior 
portion of the neck, or the face. The later in the course of 
the disease they occur, the more they are apt to form but a 
single group. If uninfluenced by treatment, tubercles may 
continue to form for years, the old ones disappearing and 
new ones coming. They disappear either by absorption, or 
by softening or breaking down and forming a sharply cut 
ulcer with perpendicular edges and yellow sloughing base. 
A number of the lesions breaking down at once and coalescing, 
a large ulcer with scalloped border, indicating its composi- 
tion from single lesions, and with more or less thick green- 
ish crust, will form. In either case they leave depressed, 
smooth cicatrices, at first pigmented, but later white. They 
give rise to no subjective disturbances. Rarely do they 
form a general eruption. 

The diagnosis of this form of syphilide is usually readily 
arrived at by finding other symptoms of syphilis. Occasion- 
ally it may be confounded with lupus vulgaris and leprosy. 



SYPHILIS. 



497 



From lupus it is differentiated by the comparative rapidity 
of its course, lupus being a disease of exceeding slowness 
of development; by its occurrence in mature years, lupus 
being a disease of youth ; by its sharp-cut round ulcers ; 
by its thick greenish crusts, and by the smoothness 
of its cicatrices, those of lupus being puckered and de- 
forming. Syphilis at times bears a striking resemblance 
to leprosy when its tubercles are located in the eyebrows, 
face, and ears, but the absence of anaesthesia is a positive 
diagnostic sign against leprosy. Moreover, other symptoms 
of leprosy, such as swelling of the ulnar nerves and pecu- 
liar brown patches, will be absent. 

The squamous syphilide is not usually described, as it is 
a modified form of either the papular or tubercular lesion. 



Fig. 59. 




V 



Squamous serpiginous syphilide. (After Lassar.) 



In using the term here, I follow my esteemed master, Pro- 
fessor George H- Fox, and like* him adopt it purely on 
clinical grounds. He applies thelterm to scaly patches of 



498 DISEASES OF THE SKIK 

circular or irregular form that occur after the first year of 
syphilis. These patches are covered with thin horny scales 
seated upon an infiltrated base. We may have one of two 
forms : the discoid, or the circinate. The discoid form is 
almost peculiar to the palms and soles and neighboring 
parts, and constitutes the only apparent lesion. The round 
patch of varying size, but with a sharply defined reddish 
seam beyond the scaling, and an infiltrated base, tends to 
become serpiginous, creeping over a considerable portion of 
the skin. Sometimes while it advances at one border, it 
heals at the other ; at other times it clears up in the center, 
leaving an elevated, scaling marginal ring. The ring may 
be broken and leave a curved line, and if two or more of 
these lines meet, we have a gyrate figure. Usually but one 
palm or sole is involved. The skin is apt to crack in the 
natural creases, and then the patient will suffer some pain 
and discomfort. It is always an obstinate lesion to cure, 
persisting sometimes for months or years. The circinate 
form differs from the just-described one in being annular 
from the first, and in occurring not only on the palms and 
soles but elsewhere on the body. 

The diagnosis of this form of syphilide from a squamous 
eczema of the palm is often one of great difficulty. The fact 
that only one palm is affected is always suggestive of syphilis. 
Moreover, in syphilis there is more infiltration and much 
less itching. Indeed, the latter may be entirely absent. 
In syphilis the lesion is often crescentic, with sound skin 
between the horns of the crescent. This is never seen in 
eczema. Psoriasis of the palm is, in most cases, not to be 
thought of as a stumbling-block in diagnosis, as it is exceed- 
ingly rare for psoriasis to affect the palms, and then only as 
a part of a general outbreak of the disease. Some writers 
use the term syphilitic psoriasis for the scaly palmar syphi- 
lide, but it is a most faulty method of nomenclature. 

The pustulo-crustaceous syphilide is characterized by large 
and usually deep-seated pustules or ulcers, covered by 
prominent and peculiar crusts. It is the ecthyma form of 
Taylor and other authorities. It occurs as a late form of 
the disease and as a localized one ; never as a general erup- 



SYPHILIS. 499 

tion. It may occur as a precocious syphilide. It is seen in 
debilitated subjects, and is of gradual development, without 
febrile symptoms as in the pustular syphilide. It has pre- 
ference for the scalp, face, and extremities. It assumes 
three forms, the ecthymatous, rupial, and pemphigoid. 

The ecthymatous form begins as an eruption of one or 
more round, flat pustules of a diameter of one-quarter to 
one-half inch. They may become as large as a silver half- 
dollar. They have a well-marked inflammatory areola and 
a swollen and indurated base. The pus soon dries and forms 
a flat, greenish or brownish-black crust, whose center is 
sometimes depressed. At first the crust fully covers the 
pustule, but later, either through drying or on account of an 
increase in the size of the pustule, a raw rim is left around 
it. When it is now removed it exposes a typical punched- 
out ulcer with its base covered with sanious pus, which 
rapidly dries into a new crust. Under proper treatment the 
pustule heals, and when the crust falls there will be left a 
healed or nearly healed ulcer. A permanent cicatrix is left 
when healing is completed, which is smooth and white 
eventually. This syphilide is seen most often on the legs 
and arms. If the course of the disease is not checked, the 
crust is cast off by increased suppuration, and the ulcerative 
syphilide is before us. 

The second variety of the pustulo-crustaceous syphilide is 
that which is commonly known as rupia. It differs from the 
preceding variety in being more superficial at the beginning 
and in forming a conical, laminated crust, somewhat resem- 
bling an oyster-shell. It begins either as a superficial pus- 
tule or a small flattened bulla with no inflammatory indura- 
tion. Upon the primary lesion a greenish crust develops, 
under which ulceration, with suppuration, occurs. The mar- 
gin of the ulceration extends a little beyond the original 
crust. A new crust forms upon it, raising up the original 
one, and this process being repeated, at last a laminated crust 
is formed. When the ulceration extends more rapidly in 
one direction than another it will follow that the crust will 
be higher at one end than at the other. Crusts may form 
a half-inch or more in height, and one or two inches in 



500 DTSEASES OF THE SKIN. 

diameter. If the lesions are numerous, they are usually 
small ; if few, large. When these thick conical crusts are 
removed the ulcer is exposed and is less deep than in the 
ecthymatous form. On healing, a permanent, smooth, white 
cicatrix is left at last. 

The third variety of the pustulo-crustaceous syphilide is 
the pemphigoid or bullous form. It is a very rare lesion in 
acquired syphilis, though quite cooimon in hereditary dis- 
ease. It consists in an eruption of superficial, purulent, flat- 
tened bullae from one to five centimetres in diameter, which 
tend to dry into thick crusts. They are surrounded by a 
dull-red areola, and are soon covered by dark greenish-black 
adherent crusts. If the patient be in fair health, the ulcera- 
tion under the crusts will not be deep. If the patient be a 
broken-down subject, the ulceration may be very deep. It 
will leave either a pigmented atrophic spot, or a pronounced 
scar, according to the depth of the ulceration. 

The diagnosis of the pustulo-crustaceous syphilide is usu- 
ally easy if the disease is known to the observer, as no non- 
specific disease resembles it closely. The so-called ecthyma 
cachecticum is more inflammatory than is the ecthymatous 
syphilide, and more superficial. The bullous syphilide 
often bears a striking resemblance to pemphigus, and can 
be diagnosed only by a study of all the features of the case. 

The gummous syphilide is perhaps one of the most char- 
acteristic of the late lesions of syphilis. It consists in a 
deposit of gummy material in the skin. The distinction 
between some tubercular lesions and a gumma is often very 
indistinct, and made principally by the size. The gumma 
begins in the subcutaneous tissue and involves the skin sec- 
ondarily. It may take the form of a single tumor, a group 
of nodules, or a diffused infiltrated patch. It is nearly 
always a late lesion, and while it may undergo absorption 
it possesses a strong tendency to break down and ulcerate. 
(Fig. 60.) i 

The single tumor begins as a small pea-sized nodule, 
seated in the subcutaneous tissues so deeply as to be appre- 
ciated only by the touch. It grows slowly ; in the course 
of weeks or months it may attain the size of a nut and push 



SYPHILIS. 501 

up the skin over it into an evident tumor, which is movable, 
firm, elastic, painless, and rolls under the finger. Increas- 
ing in size, it involves the skin, which then becomes of a 
dull reddish color. When the skin becomes involved the 
tumor is no longer movable, and soon fluctuation may be 
felt that would lead the inexperienced to open it as an ab- 
scess. If he did so. it would be a mistake. He would find 
only a little pus, a gummy substance, and some blood. Left 
to itself, the tumor may be absorbed, or it may break down 
and ulcerate, leaving a characteristic deep and round ulcer. 

Fig. 60. 




Gurninata. (After Juli/ien.) 

The scalp and forehead are the chosen sites for this syphi- 
lide, though it may occur anywhere. It sometimes attains a 
large size — as large as a hen's egg. When this lesion oc- 
curs as a precocious syphilide it is usually of small size and 
multiple. 

When gummata occur in the form of grouped nodules the 
skin between them is apt to become infiltrated with a gum- 
matous deposit, and the patch will present the dull brownish- 

22* 



502 DISEASES OF THE SKIN. 

red color of the late syphilides. The individual members of 
the group run a course similar to that of the isolated gumma, 
but do not attain its size. When they break down they form 
a large irregular ulcer. This variety of the gumma is fre- 
quently met with upon the scalp, the nose, the outer aspects 
of the extremities about the joints, and around the lower 
portion of the leg and ankle. Diffuse gummatous infiltra- 
tion of the skin probably precedes all serpiginous ulcerations. 
Apart from this it is rarely seen, and almost always ends in 
ulceration. 

Other gummatous deposits are known as syphilitic dac- 
tylitis, admirably described by R. W. Taylor, and syph- 
ilitic bursitis, carefully studied by E. L. Keyes. One being 
a bony and the other a synovial disease, they do not here 
concern us. 

The diagnosis of the gumma must be made with care. It 
may simulate other forms of tumors. It is not as hard as 
the sarcoma, nor as compressible as the lipoma, and it in- 
vades the skin. An abscess is usually attended by pain and 
signs of inflammation, and runs a more acute course than 
does the gumma. 

The ulcerative syphilide, according to Prof. George H. 
Fox, merits being described by itself, though in itself only a 
sequence of a tubercular pustulo-crustaceous, or gummatous 
syphilide ; because in the majority of cases of syphilitic ulcers 
met with it is hard or impossible for us to say what the pre- 
ceding lesion has been. For convenience, he describes the 
superficial, the serpiginous, and the deep or perforating 
forms of syphilitic ulceration. 

The superficial syphilitic ulcer is circular, with sharply 
cut edges and dirty-yellowish purulent base. It most often 
follows a pustular or pustulo-crustaceous lesion, and may 
appear comparatively early in the disease, especially in de- 
bilitated subjects. It is usually of the size of a quarter- 
or half-dollar, and frequently coalesces with other ulcers to 
form ulcerative patches with scalloped margins. The face 
and legs are its most common sites. 

The serpiginous ulcer is so called because it tends to creep 



SYPHILIS. 503 

over the surface, healing by a cicatrix as it passes along. 
It may develop from a single circular ulcer healing in the 
middle and at one side, and leaving a crescentic or " horse- 
shoe " ulcer at the other side, with a sharp convex margin, 
beyond which is a narrow zone of infiltration upon which 
the ulceration constantly encroaches, while healing at its 
concave border. Or a group of crusted pustules or softening 
tubercles form a number of small round ulcers, of which the 
outer ones usually form a curving line. While those in the 
center and at one side tend to heal, new lesions develop at 
the periphery of the opposite side, which ulcerate and per- 
haps coalesce, and so the disease creeps on. This form is 
often observed upon the back and on the extremities ; it is 
not particularly painful, and the patient's health may not be 
impaired. 

The deep ulcerations of syphilis result, for the most part, 
from the breaking down of gummatous deposits. The small 
ones are crater-like in shape. Often the opening of the 
softened tumor is smaller than the softened mass, and it is 
not infrequent to find the cavities of adjacent tumors run- 
ning together subcutaneously. 

Ulcerative syphilides sometimes are covered with exu- 
berant granulations. 

The diagnosis of syphilitic ulcers from non-specific 
ulcers is most important from a therapeutical standpoint. 
A chronic ulcer located anywhere above the middle half of 
the leg is in most cases syphilitic. If it is not, it is probably 
either traumatic, tubercular, or cancerous. The traumatic 
ulcer is acute and highly inflammatory ; of irregular shape ; 
has a history of traumatism ; and heals rapidly, excepting 
in very broken-down subjects, under simple dressings. The 
tubercular ulcer, if from broken-down caseous glands, has 
a history of the previous glandular affection ; is irregular in 
shape ; often presents a number of sinuses and ridges of in- 
flamed tissues ; and runs a sluggish course. If it is a lupous 
ulcer, there will be found somewhere in the neighborhood the 
characteristic apply-jelly-like tubercles ; there will be a his- 
tory of lasting from early life ; the edges of the ulcer will 
be shelving or undermined ; and there will usually be more 



504 DISEASES OF THE SKIN. 

or less deforming cicatrices present. A cancerous ulcer, 
usually an epithelioma, will have a history of beginning in 
a pimple, wart, mole, or such like; will be irregular in 
shape with an uneven floor ; will be apt to to be attended by 
lancinating pain ; will usually be a single lesion, located on 
the face ; and will have a raised, waxy, rolled-out border 
over which delicate bloodvessels will be seen to course. 

The diagnosis of ulcers of the leg lies between one of 
syphilis and of varicose dermatitis. If the ulcer is irregular 
in shape with shelving edges, rather superficial, surrounded 
by a brawny, infiltrated, brownish or dark-red tissue with 
more or less scaling, and there are varicose veins above it, we 
have to do with the so-called varicose ulcer. This is in 
sharp contrast with the round, or scalloped bordered, deep, 
punched-out ulcer with perpendicular edges and greenish 
base, around which there is but a small zone of redness. 
The diagnosis of syphilis is strengthened when we find a 
number of ulcers, or the cicatrices of old ulcers. As a rule 
the syphilitic ulcer is located on the posterior surface of the 
upper half of the leg, while the varicose ulcer is on the ante- 
rior surface of the lower third of the leg. The diagnosis 
from a traumatic ulcer has already been given. 

Over the pigmentary syphilide there has been no little 
discussion. By this term is not meant pigmentation follow- 
ing a syphilide which is sufficiently common, and due to a 
staining of the skin with hsematin: but a true pigmenta- 
tion without antecedent lesion, and is most always seen on 
the sides of the neck, and in women. It is composed of 
irregularly round or oval spots, one-eighth of an inch to 
one inch in diameter, with ill-defined margins, and cafS-au- 
lait color, which does not fade on pressure. The color may 
be very faint. They may be discrete or confluent. When 
they are very numerous they have been compared by Four- 
nier to a " network of lace with large meshes." It is one 
of the rarer manifestations of syphilis. 

General Diagnosis of Syphilis. Having now studied 
briefly the various cutaneous lesions of syphilis, we are pre- 
pared to state those general features of the syphilides that 
serve to distinguish them from other diseases of the skin. 



SYPHILIS. 505 

One marked feature of them is that they do not itch. 
Itching does occasionally occur with the scaling papular 
syphilide ; and in some cases the patient will complain of 
an itching of the skin that is quite independent of syphilis, 
but in themselves they do not itch. 

The early eruptions of syphilis are general and exhibit a 
marked polymorphism, many different lesions being often 
present at the same time ; as, for instance, macules, papules, 
and pustules. The late eruptions exhibit a strong tend- 
ency to grouping of the lesions in circles and segments of 
circles. 

The color of the lesions is peculiar, and perhaps may be 
best described as that of raw ham, though the classic term 
is " copper." This color is by no means always present. 
It is not seen in the early bloom of the early lesions, but is 
pretty sure to be found in those that have existed for some 
time, and in the late lesions. The color of a lesion on the 
legs, it must be remembered, must not be regarded for pur- 
poses of diagnosis ; it is upon the arms, face, trunk, and 
thighs that we must look. 

Painlessness is often a suggestive symptom pointing 
toward syphilis when we have to decide as to the nature 
of an ulceration. 

It is well not to lay too much stress upon the history of 
the case in making up our mind as to a late syphilide, be- 
cause with the best intentions the patient may forget hav- 
ing had an insignificant initial lesion some twenty, or per- 
haps thirty, years before. 

Space will not permit of our here detailing the differential 
diagnosis between syphilis and the many diseases which it 
may simulate from time to time. For this the reader must 
be referred to the sections upon eczema, psoriasis, lupus, 
alopecia, etc. 

Etiology. That acquired syphilis is due to contagion 
we know. Further than this we know little of certainty. 
Various attempts have been made to prove its bacillary 
origin, by Lustgarten and others, but at present the best 
authorities are by no means agreed upon the correctness of 



506 DISEASES OF THE SKIN. 

this theory. 1 We can, in the meantime, speak of its being 
due to a specific virus. The microbian theory is also ap- 
plied to all pustular syphilides, and we are taught that they 
are the result of an injection of the specific lesion by the 
pus-coccus. 

Hereditary Syphilis. Before entering upon the study of 
the treatment of syphilis, we must stop a while to consider 
hereditary syphilis. This differs from the acquired form in 
having no initial lesion, the disease being acquired in utero 
from either one or both parents. We cannot enter upon a 
discussion of the many conflicting theories as to whether or 
not the child is diseased on account of springing from a dis- 
eased ovum, or spermatozoa ; or the possibility of the dis- 
ease, acquired by the mother after her pregnancy, reaching 
the foetus through the placental circulation ; or like interest- 
ing questions over which the battle rages. For us now it 
suffices to make the bald statement that the disease may be 
acquired from one or both parents. It is most sure to be 
acquired from the mother, and it may be inherited by the 
foetus from a mother infected some months after conception. 
It is possible for a woman to show no signs herself of syph- 
ilis, and yet to give birth to a syphilitic child. It is ex- 
ceedingly rare for the apparently healthy mother of a child 
hereditarily syphilitic to be infected by it. As a result of 
syphilitic infection in utero, the child may be born prema- 
turely, and dead ; it may be born at term, dead, and show- 
ing specific lesions ; or it may be born alive with some 
syphilitic eruption ; or, as is commonly the case, the erup- 
tion may not appear before the second or third week. 
Miller, 2 from a study of one thousand cases of congenital 
syphilis in a foundling hospital in Moscow, found that the 
first appearance of the disease was in the first month of life 
in 64 per cent, of the cases ; and in the second month in 22 
per cent. In congenital syphilis there is a marked absence 
of that sequence of events more or less observed in acquired 

1 For a good study of the probable origin of svphilis consult Finger, 
Archiv. Derm, und Syph. , 1890, p. 331. 

2 Jahrb. der Kinderheilk., 1888, xxvii. Heft 4. 



SYPHILIS. 507 

syphilis, but the diagnosis is usually quite as easy. The 
earliest eruption to appear, as to point of time, is, according 
to Miller, the bullous syphilide, which he met with in 25 
per cent, of the cases. One of the earliest and most char- 
acteristic symptoms of hereditary syphilis is " snuffles, iy due 
to an ozsena, which gives the child great discomfort by inter- 
fering with breathing and nursing. 

The erythematous syphilide is, according to Taylor, the 
most frequent and earliest eruption ; according to Miller, 
it occurs in but 45 per cent, of the cases. It begins on 
the lower part of the abdomen as minute round or oval 
spots, that disappear under pressure at first. It invades 
the whole body within a week, when the lesions will no 
longer fade under pressure, but assume the characteristic 
syphilitic color. One form of the erythematous syphilide 
in children is seen upon the inside of the thighs, about the 
anus, and on the buttocks, and may extend down to the 
feet. It is patchy in character, the patches being either of 
small size, or large by the coalescence of several smaller 
ones. It differs from intertrigo by its patchy character, by 
its darker color, and by its wider distribution. 

The papular syphilide and its modified forms of the mu- 
cous patch and the condylomata lata are common congeni- 
tal lesions. The lenticular syphilide, large and small, is 
met with far more frequently than the miliary papular 
syphilide. It is usually a symmetrical and general erup- 
tion. It may be smooth or scaly, and always has the raw- 
ham color. Mucous patches are very often at the junction 
of the mucous membrane and the skin, as on the lips or 
anal orifice. The movements of the parts will give rise to 
painful fissures, rhagades, which constitute a sign of heredi- 
tary syphilis as characteristic as the " snuffles." These 
rhagades Miller met with in 70 per cent, of his cases. 
Mucous patches also occur in the cavity of the mouth. 
Condylomata lata occur where two skin surfaces rub to- 
gether, and especially where there is more or less moisture, 
as about the anus and genitals, in the groins and axillse, and 
between the fingers and toes. Their color is usually gray- 
ish-pink to dark-brown ; their size varies greatly, and their 



508 DISEASES OF THE SKIN. 

surface is flat, or fissured and ulcerated, and exudes an offen- 
sive secretion. They are characteristically located when at 
the angles of the mouth, in combination with mucous patches 
in the mouth with rhagades between. 

The pustular syphilide may be general, but is usually 
most pronounced on the thighs, buttocks, and face. It 
shows a tendency to group about the mouth. It is usually 
indicative of profound syphilization. The pustules may 
leave scars. Ecthymatous pustules may develop, but usually 
not till late in the disease. 

The vesicular syphilide is a rare form of early congenital 
syphilis of severe type. It is never general, but appears as 
groups of closely packed together vesicles upon the chin, 
about the mouth, or on the nates, forearms, hypogastrium, 
or thighs. They are seated upon infiltrated, brownish-red 
bases. The larger vesicles may be seated upon papules. 
This eruption is apt to be associated w r itL a pustular or bul- 
lous syphilide. 

The bullous syphilide, unlike what obtains in adults, is 
comparatively common in congenital infantile syphilis. 
Miller found it in twenty-five per cent, of his cases. It 
frequently exists at birth or as the earliest syphilide, and is 
indicative of a severe form. It is most commonly seen on 
the palms and soles, which are often covered with the lesions, 
while few, if any, are on the trunk. The face is a favorite 
location for the eruption. They are either tense or flaccid ; 
at first have sero-purulent contents that soon become puru- 
lent. They are seated upon a raw-ham colored infiltrated 
base. Hemorrhage into them not infrequently occurs. 
When they rupture or dry up they exhibit an unhealthy- 
looking ulceration that soon becomes covered with a green- 
ish crust. Some of them may dry up with little, if any, 
ulceration. It rarely relapses. It differs from pemphigus 
in occurring upon the palms and soles, while sparing the 
trunk, and in the profound cachexia and the presence of other 
signs of syphilis. 

The tubercular syphilide is not common, and is always a 
late lesion. While it may be seen as early as the sixth 
month, it is more apt to occur much later as a relapsing 



SYPHILIS. 509 

syphilide. In appearance and course it resembles the same 
lesion of acquired syphilis. 

The gummatous syphilide is also a late manifestation of 
disease, and is sometimes met with in early adult life as a 
lesion of congenital syphilis. 

Kaposi regards as a special and characteristic symptom 
of hereditary syphilis a diffused infiltration of the palms 
and soles, the skin of which is uniformly brownish-red, dry, 
shiny, and fissured. 

Besides the skin-lesions the infant bears certain unmistak- 
able signs of syphilis. It has a marked pallor, and, no mat- 
ter how blooming it may appear at first, it soon loses flesh 



Fig. 61. 




Hutchinson's teeth. 

and assumes " an old man'' countenance. It has a charac- 
teristic, hoarse, toneless cry, which once heard will be re- 
membered. Its hair is scanty, its nose is apt to be flattened, 
and altogether it is a most woebegone-looking object. The 
skin eruptions usually occur within the first six months of 
life, and if the child can be brought through that period it 
may suffer no more. Nevertheless, congenital syphilis, like 
the acquired disease, may be latent for years to crop out 
once more. The victims of congenital syphilis sometimes 
show the notched or peg-shaped teeth regarded by Hutchin- 



510 



DISEASES OF THE SKIN, 



son as a certain sign of the disease. (Fig. 61.) This ap- 
pearance is presented by the second set of teeth only, and 
is not absolutely diagnostic, as the same has been met with 
in scrofula. The two middle upper incisors are those which 
are depended on for diagnosis. " They are small, often 
converging, sometimes diverging. The cutting-edge of the 
teeth is sometimes narrowed, rounded off. They are stunted 
and badly developed, often marked with seams in front, and 
of a dirty-brownish color, but their chief peculiarity is found 
in their edges, which, being thin when cut, break off cen- 
trally, leaving a broad, shallow, vertical notch on the lower 
border of the tooth." (Keyes.) It is subject to diseases of 
the bones, one of the most characteristic of which is dactylitis. 



Fig. 62. 




Dactylitis. (After Bergh.) 



Space will not permit of a detailed description of the bone 
and other lesions apart from those of the skin. 

Treatment. The treatment of syphilis is by the use of 
both constitutional and local remedies, and by a constant and 
long-continued watchfulness on the part of the physician 
over the patient's hygiene and general well-being. One 
chief obstacle to the successful treatment of a case is the 
patient's lack of faith in his physician. Most patients, just 
as soon as the eruption for which they sought advice fades 
away, will cease coming to the physician, and will pay little 
heed to his warning that unless they keep themselves under 
medical supervision for three or four years they will be 
liable to serious troubles later on. Nevertheless, our first 
duty is so to instruct them. Then before putting the patient 



SYPHILIS. 511 

upon a regular course of treatment, we should give him 
careful direction as to his exercise, liberal diet, and bathing, 
and should stop his alcohol, insist upon his taking plenty of 
sleep, and giving up the use of tobacco. This last is not 
only to put him in better condition, but also to prevent 
mucous patches in the mouth. The patient should be cau- 
tioned against drinking out of public drinking-cups, and 
apprised of the danger of infection of others by means of 
table utensils, pipes, and the like. Now he is ready for his 
course of treatment. 

Constitutional Treatment. The drugs employed and 
found of value in syphilis are chiefly but two, namely : mer- 
cury and iodine in combination with sodium or potassium. 
These drugs are given in varying combination, and during 
varying periods, according to the views of different physi- 
cians. Mercury is the remedy relied on most for combating 
the disease, and should be used under ordinary circum- 
stances by itself alone during the first year or two of the 
disease. The iodides exercise a marked control over the 
ulcerative syphilides, and in the late or precocious mani- 
festations of the disease. By some they are given continu- 
ously or as the sole remedy in late syphilis, but the best 
practice is in favor of their administration either with mer- 
cury or instead of mercury for a short time. Treatment 
should be begun as soon as we are sure that the patient has 
syphilis. As an element of doubt may often enter into our 
diagnosis of the initial lesion, it is a good general rule not to 
administer specific treatment until the appearance of some 
secondary symptom. This plan has the additional advan- 
tage of producing a moral effect upon the patient, who, if he 
sees an eruption upon himself, will be more apt to believe 
that he has syphilis, and to submit himself to a thorough 
course of treatment. 

We will consider first the treatment of early syphilis and 
the use of Mercury. This drug, regarded by the majority 
of physicians as the sheet-anchor in the treatment of syph- 
ilis, is administered, for its constitutional effect, by the 
mouth, by inunction, by fumigation, and by hypodermic 
injection. 



512 DISEASES OF THE SKIN. 

Of these different methods the most frequently employed 
is the first — that is, by the mouth. The salt of mercury that 
I most frequently use is the protiodide, otherwise called the 
green iodide. This may be exhibited either in pill, tablet 
triturate, or granule; and as the tablet triturate is easily 
obtainable, very reliable, and quite inexpensive, my prefer- 
ence is for that preparation. Keyes prefers the granules of 
French manufacture, and says that the very objection raised 
by many authorities to the use of the protiodide, namely, its 
irritant effect on the intestinal tract, is its shining virtue, 
because instead of giving warning of intoxication by causing 
salivation, it does so by causing diarrhoea. The dose to 
begin with should be from one-sixth to one-fifth of a grain 
three times a day after meals, and the number of pills in- 
creased every third or fourth day until there is a little 
" colicky diarrhoea." The dosage should be then continued 
at the same number of pills, until the symptoms are con- 
trolled. Then we can reduce it to half the number. It may 
be necessary to give a little opium at the same time with the 
mercury in order to control the diarrhoea if it is deemed 
advisable to continue at the point of full tolerance, and this 
not only with the protiodide but with other salts. Practi- 
cally the daily dose of the protiodide may be put at four or 
five of the one-fifth grain tablets, and three or four of the 
quarter-grain ones, and opium is rarely called for. 

Many prefer to use metallic mercury, hydrarg. cum creta, 
or calomel in the dose of one or two grains two or three 
times a day after meals, iucreased every three or four days 
sufficiently to influence the eruption. Salivation is, in the 
general run of cases, to be avoided. Some authorities pre- 
fer to combine a tonic with the mercury. Taylor gives the 
following; 

K. Hydrarg. protiodid., gr. viij-x. 

Ferri et quiniee citrat. , 3 iss 

Ext. hyoscyanri, gr. vj. M. 



or 



Ft. pil. no. xxx. 

K. Hydrarg. tannici, gr xv-xxx. 

Quin. sulphat., ^j. 

Ext. hyoscyami, gr. vj. M. 

Ft. pil. no. xxx. 



SYPHILIS. 513 

In severe cases in which it is necessary to get the patient 
rapidly under the influence of mercury, calomel in one- 
tenth-grain doses in the form of tablet triturates may be 
given every hour until the gums become tender. Then the 
calomel should be stopped and the treatment continued with 
a small dose of the protiodide. 

Besides these preparations of mercury we may use the 
bichloride in doses of -^-to -^ of a grain in solution. It is 
usually given in compound syrup of sarsaparilla or some 
bitter infusion. The most common mode of administering 
it is in combination with the iodide of potassium, the so-called 
mixed treatment, the formula for which will be given later 
when speaking of the treatment of late syphilis. The best 
opinion is in favor of reserving the use of iodine until the 
early lesions are over. The tannate of mercury is well 
spoken of in the dose of half a grain. Space will not allow 
of mentioning the other salts of mercury that have been 
recommended. 

The proper quantity for administration having been 
learned by experiment, the drug should be administered 
continuously for from four to six months. 

Where practicable the use of mercury by inunction is the 
speediest and best way of getting the patient under the 
influence of the drug. It may be used from the first or at 
any time during the course of the disease. Its great ad- 
vantages are the promptness with which it acts, and the 
sparing of the stomach and intestinal tract. Its great dis- 
advantages are that it is a dirty method, impracticable with 
most patients, as it attracts notice from his friends and 
attendants; and the difficulty encountered in getting the 
patient to carry out the treatment with thoroughness. It is 
admirable for hospital treatment. The patient is to be told 
to rub into his skin, once a day, a piece of ungt. hydrarg. 
cinereum of the size of a hazelnut. He is to divide the 
mass into two equal parts, and work it in with the heel of 
his hand for about fifteen minutes, while he sits before a fire 
or in a warm room. Before beginning the inunctions he is 
to take a warm bath, or to bathe the parts about to be rubbed, 
so as to open the pores of the skin. The first day he is to 



514 DISEASES OF THE SKIN. 

rub the ointment into the bends of both elbows ; the second 
day, over the sides of the chest ; the third day, over the 
abdomen; the fourth day, inside of the thighs; and the 
fifth day, behind the knees. That is, he is to choose the 
parts least covered with hair ; and to change the sites of the 
inunctions so as to avoid setting up a mercurial eczema. On 
the sixth day he is to take another bath, and begin on the 
seventh day. The treatment is to be pursued until active 
symptoms of the disease are overcome, when all treatment 
may be suspended. A thorough course of, say, eighty or a 
hundred inunctions is said to be often followed by a perma- 
nent cure. If the inunctions are to be made by an attend- 
ant, he should wear a stout rubber gWe. 

Fumigation is a method which is not used as much now 
as formerly. It requires the use of a special apparatus, and 
a great amount of time and trouble. Inasmuch as it pos- 
sesses no advantage over inunctions, we will say no more 
about it. 

The hypodermatic injection method of administering mer- 
cury, or rather the deep intra-muscular method, was first 
advocated by Scarenzio in 1854, and of late years has been 
much experimented with. The injections are usually made 
deep down in the gluteal region, behind and above the great 
trochanter. They are usually painful; often followed by 
abscesses ; require daily or frequent visits to the physician's 
office ; and do not seem to be followed by sufficiently lasting 
effects to warrant their frequent employment. They are 
useful where we wish to have a very prompt effect from the 
mercury, as in a malignant precocious case of syphilis ; or 
where the stomach must be spared ; or where the disease 
has not yielded to the ordinary plans of treatment. Patients 
in this country seem to object very strongly to their employ- 
ment. A vast number of salts of mercury and combinations 
have been introduced, each one of which has been found by 
its introducer the best and most reliable. An admirable 
study of them will be found in Hare's System of Therapeu- 
tics, vol. ii., by Prof. R. W. Taylor. Here we can indicate, 
and briefly, but a few. Taylor gives one of corrosive subli- 



SYPHILIS, 515 

mate, gr. xl ; glycerin, 3j ; distilled water, 5iij ; of which 
twelve drops are used at each injection. The albuminate of 
mercury, dose 15 minims; the formamide (Liebreich), dose 
one-half to a whole Pravaz syringeful of a one per cent, 
solution; calomel, 1 part, to liquid vaseline, 12 parts, dose 
a half Pravaz syringeful once a week ; " gray oil," com- 
posed of 20 parts of pure mercury, 40 of liquid vaseline, 
and 5 of ethereal tincture of benzoin, dose one-third of a 
syringeful every ninth day ; l salicylate, 15 grains to the 
ounce, and many others. A final judgment as to the com- 
parative merits of the many salts cannot yet be given. 

Late Syphilis. If a patient who has not been under 
systematic treatment comes to us with a late syphilide, the 
so-called mixed treatment will be most appropriate to his 
case. As usually administered it is made up according to 
one of the following formulas : 



R. Hydrarg. bichlor. , vel \ % ._.. 

Hydrarg. biniodidi, J & J J- 

Potass, iodidi, 3J~ij- 

Inf. gentian co., vel 1 1 ?' 

Syr. sarsaparilloe co., / ' o • ]\j 

Dose : A teaspoonful three time a day after meals. 

Or, 

1£. Hydrarg. biniodidi, gr. ss-ij. 

Amnion, iodidi, ^ss. 

Potass, iodide, .^ij-^j- 

Syr. aurant. cort., ^jss 

Tr. aurant. cort., 3j\ 

Aquae, q. s ad ^iij- M. 

Dose : A teaspoonful, in water, three times a day. (Keyes ) 

If a patient comes to us with a gumma, an ulcerative 
syphilide, a group of serpiginous tubercular syphilides of 
the tertiary period; or if any of these or other deep lesions 
threatening destruction of tissue appear early in a case of 
prococious or malignant syphilis ; or if the disease attacks 
the nervous system, the larynx, pharynx, or eye ; in fact, at 

1 Leloir and Ta vernier: Giorn. ital. d. Mai Ven. e del Pelle, 1889, 
xxiv. 247. 



516 DISEASES OF THE SKIN. 

any time when there is need of prompt effects, we must ad- 
minister the iodides. If he has had no mercury for some 
time, it is best to give it to him now either by the mouth, 
mixed treatment, or inunctions, while the iodide is adminis- 
tered separately, but at the same time. The iodide of 
potassium is most generally used, and next to it the iodide 
of sodium. There is no set dose for the iodide. It is best 
given in a dose of five grains in solution in water, three 
times a day, before meals, diluted in milk, or Vichy, or soda- 
water ; or some three hours after meals. Delavan 1 has found 
that the iodide can be given most satisfactorily by putting 
five drops of a saturated solution in the bottom of a small 
tumbler, with fifteen drops of essence of pepsin, and pouring 
upon it two ounces of warm milk. This is to be set away 
in a cool place, and will form a rennet custard, which can 
be easily swallowed. This is a good method when we wish 
to give nourishment with the medicine, and the mixture can 
be given a pleasant taste by adding a teaspoonful of sherry 
wine. 

The dose should be increased by one or two drops each 
day ; that is, six drops t. i. d. ; then seven drops t. i. d., 
and so on, until the nose runs and the eyes water, or some 
symptom of iodism develops. The most convenient method 
of administration is to have a solution made containing 
one grain of the iodide to each drop of the solution, so 
that every drop represents a grain. Most patients bear 
iodine well, but in some even drop doses produce iodism. 
Iodic acne is very often induced, but should not cause us to 
stop using the drug. It is advisable to suspend the admin- 
istration of the iodides from time to time, and to give mer- 
cury, which, after all, must be depended on for curing 
syphilis. 

Now and again we will meet with cases that do not im- 
prove either under mercury or iodine, but relapse and relapse. 
Such cases should be sent out of town, ordered change of 
air for a time, and put on a purely tonic course of treatment. 
Very often when the patient returns home he can take his 

1 Med. Record, 1891, xl. 651 



SYPHILIS. 517 

medication easily, and the previously obstinate lesions will 
yield readily. This is but what we said at first ; the pa- 
tient's general condition must all the time be carefully 
watched over. 

Salivation is an unpleasant accident that may occur under 
the use of either mercury or iodine. At one time it was 
quite common ; indeed, mercury was purposely pushed so 
far as " to touch the gums," and, of course, this was often 
overdone. Its symptoms are tenderness of the teeth, so that 
pain is felt when the jaws are snapped together ; the gums 
are swollen ; there is a metallic taste in the mouth ; a fetid 
odor of the breath ; increased flow of saliva by day and 
night; all the mucous membranes of the mouth are swollen, 
so much so as to interfere with mastication and deglutition, 
and in very bad cases there may be ulceration, loosening 
and fall of the teeth, and caries of the bones. 

Prevention is always better than cure, and to this end we 
should see that our patient's teeth are in good order before 
beginning treatment, and direct him to wash his mouth fre- 
quently with chlorate of potash solution, ten or fifteen grains 
to the ounce, or one of alum, and to keep his teeth clean. The 
patient should be seen frequently at first, so as to stop the 
mercury before salivation attains any serious degree. Sali- 
vation having begun, the mercury must be stopped, and the 
potash solution in same strength may be continued, and one 
or two drachms of it swallowed during the day. Dilute 
solutions of Labarraque's solution, or permanganate of pot- 
ash, or other astringent, may be used for a gargle and 
mouth-wash. A laxative should be administered, the 
patient kept warm in bed, and, if necessary, an anodyne 
given. 

Duration of mercurial treatment. How long the patient 
should take mercury is a question, the answer to which is 
very variously given by different authorities. Keyes puts 
it at from eighteen months to four years. Taylor says 
" at least two years to two years and a half, counting from 
the date of the commencement," but he advocates intermis- 
sions of from two to three months, iodide of potassium being 

23 



518 DISEASES OF THE SKIN. 

given in the meantime. Schwimmer 1 advocates giving mer- 
cury for two or three months, and then one of the iodides for 
two months ; after four or five months of treatment making 
a pause of two or three months, treating any local lesion 
locally, and then repeating the course. Fournier 2 usually 
administers mercury for six to nine weeks; then pauses 
six weeks ; then gives another six weeks' medication. Dur- 
ing the first year he puts the patient through four courses ; 
during the second year, three courses ; and during the third 
year, two courses. During the fourth year he gives the 
iodide alone for six weeks, with corresponding intervals. 
Crocker advises stopping mercury about every six weeks to 
give the iodide for a week or ten days. At the end of six 
months, if the patient has been free from symptoms for two 
or three months, a month's pause may be made, to be fol- 
lowed by a six weeks' course of mercury. And so through 
the first year. During the second year he alternates a six 
weeks' mild mercurial course with a one or two weeks' course 
of the iodide. If still free from lesions, treatment may be 
suspended until some symptom crops out. 

Against these advocates of long-continued mercurial 
treatment there are others, no less eminent, who advocate 
the administration of mercury only during the duration of 
the symptoms, and for a few months afterward ; then they 
advise to suspend all treatment until some new outbreak of 
the disease calls for it. In combating so insidious a disease 
as syphilis, it seems to me wisest to err rather on the side 
of too long continued treatment than on that of a too short 
course. 

Local Treatment. While internal treatment by mer- 
cury and the iodides is quite competent to remove the syph- 
ilodermata, their disappearance can be materially hastened 
by local treatment by means of mercurial applications. 
Ointments of metallic mercury, of the ammoniate, the red 
oxide, and the oleate, with solutions of the bichlorides, are 
the preparations most generally employed. 

1 Second Supplement to the Monatshefte f. prakt Dermat., 1888. 

2 Gaz des Hop., 1889, No. 103. 



SYPHILIS. 519 

Many attempts have been made to abort syphilis by ex- 
cision of the initial lesion, or its destruction by means of 
caustics. These have been failures in most instances. This 
is not to be wondered at in the light of R. W. Taylor's recent 
studies, 1 which show that " in the very first days of syphi- 
litic infection the poison is deeply rooted beneath the initial 
lesion, and extends far beyond it, infecting all the parts 
beyond, even to the root of the penis." The initial lesion 
should be dressed with iodoform or calomel, or kept covered 
with dry lint powdered with either of these. 

It may be said that in all the early and generalized syph- 
ilides local treatment needs practically to be applied only to 
lesions on exposed parts ; that is, face, neck, hands, and 
wrists. The erythematous syphilide is usually so epheme- 
ral that no local treatment is necessary. Mercurial baths 
may, however, be used for general outbreaks of syphilis. 
If the erythematous lesions persist upon the exposed parts, 
their departure can be hastened by the use of the ointment 
of the ammoniate of mercury rubbed in morning and night. 
The same ointment may be applied to the papular syphilide. 
A still more prompt effect can be produced, if the patient 
can be seen often enough, by the physician touching each 
lesion with a solution of the bichloride of mercury in alcohol 
three to five grains to the ounce, according to the size of the 
lesions and the profuseness of the eruption. Of course, if the 
eruption is very profuse, this plan cannot be followed. It is 
most applicable to a sparse and relapsing eruption. The 
mucous patch should be touched with the nitrate of silver 
stick or with an aqueous solution of chromic acid, 10 grains 
to the ounce. Condylomata are best treated with dusting- 
powders, preferably calomel freely applied and covered with 
absorbent cotton. 

The squamous syphilide of the palms and soles is often 
obstinate, but will usually yield to the persistent use of 
mercurial ointment. Sometimes it will be necessary to 
soften the part by having the patient wear sheet rubber next 
the skin for several days, and then use the ointment. If 

1 Med. Eec, 1881, xl. 1. 



520 DISEASES OF THE SKIN. 

it is covered with a very much thickened epidermis, we 
may have to remove this by using salicylic acid as in chronic 
squamous eczema. Mercurial plaster worn continuously is 
efficient. 

The tubercular syphilide occurring discretely can be 
touched with the bichloride solution already mentioned. 
When in groups it is best treated by means of mercurial 
plaster. 

The gumma may be covered with mercurial plaster or 
ointment. It should not be incised unless it shows unmis- 
takable evidences of containing pus. 

Ulcers following whatever lesion may be covered with 
mercurial plaster or ointment, or dressed with iodoform or 
aristol. If they become sluggish, they may require stimula- 
tion just as a simple ulcer does. To this end we may touch 
them with balsam of Peru, or add the same to our mercurial 
ointment. Some ulcers will do best under the treatment 
applicable to a simple ulcer, while the iodide of potassium is 
pushed. 

Treatment of Congenital Infantile Syphilis. The 
most popular method is to spread upon pieces of flannel a 
piece of mercurial ointment of about the size of the end of 
the finger, and tie this one day over the elbows ; another day 
over the groins ; another, over the knees ; and another, over 
the abdomen, allowing the movements of the child to work 
the ointment into the skin. Or hydrarg. cum creta, one 
grain three times a day, may be given by the mouth. Monti 1 
recommends the following : 



&. Calomel pur., 
Ferri lactatis, 
Sacch. alb., 

Ft. in pulv. no. x. 

Sig. 1-4 powders daily. 



M. 



The greatest attention must be given to the hygiene of 
the child, and to its diet. Cod-liver oil should be given 
along with the mercurial. The nose must be kept clear, and 
if this is not practicable the child must be fed with a spoon. 

1 Archiv f. Kinderheilk., 1885, vi. i. 



TACHE CONGENITALE. 521 

After the disappearance of symptoms, put on tonics, one of 
the best being the syrup of the iodide of iron. In all other 
respects the treatment of infantile syphilis is the same as 
that of the acquired form. Kaposi commends the tannate 
of mercury for children ; dose, J gr. to f gr. , t. i. d. 

Prognosis. The prognosis of syphilis as seen at the 
present time and in this country may be said to be good. 
Many cases go no further than a general erythematous or 
papular eruption, even when untreated. In one of robust 
health the disease is usually readily manageable. In 
debilitated subjects it sometimes proves intractable. The 
worst feature of the disease is the great uncertainty of its 
course, no one being able to promise confidently, no matter 
with what treatment, that relapses and late visceral syphilis 
will not occur. Therefore, the prognosis should be guarded, 
while it is remembered that rare cases of secondary infection 
attest the possibility of complete recovery. 

The prognosis of congenital syphilis is not as good as is 
that of the disease as it affects adults. Many, perhaps 
most, of the cases seen in public institutions die. In pri- 
vate practice more can be done, and we should always count 
upon the remarkable reparative powers of childhood in 
making our prognosis. A great deal will depend upon the 
inborn vigor of the child. 

Syringomyelia (SiVPn-go-mi-elV-a 3 ) is a disease of the 
spinal cord, the consideration of which belongs rather to 
the neurologist than the dermatologist. It interests us be- 
cause various cutaneous lesions occur during its course, such 
as glossy skin, hyperkeratosis, hyperidrosis, and paronychia 
with necrosis of the phalanges ; and because in some phases 
it resembles certain stages of leprosy 

Syringo-cystadenoma. See Epithelioma, multiple be- 
nign, cystic. 

Tache Atrophique. See Atrophoderma. 

Tache Bleue. See Pediculosis. 

Tache Cafe'-au-lait. See Nsevus. 

Tache Congenitale. See Nsevus. 



522 DISEASES OF THE SKIN 

Tache de Feu. See Ngevus. 
Tache Hemorrhagique. See Nsevus. 
Tache Hepatique. See Chloasma. 
Tache Ombrees. See Pediculosis. 
Tache Pigmentaire. See Nsevus. 
Tache Vasculaire. See Nsevus. 
Tache Vineuse. See Naevus. 
Tan. See Lentigo. 
Tanne. See Acne. 

Tattoo. These well-known stainings of the skin by means 
of India-ink, vermilion, charcoal, and gunpowder, although 
at first objects of pride to the boy or girl, later are apt to 
become objects of aversion. They are very difficult to re- 
move ; indeed, it is almost impossible to remove them if they 
are at all extensive. Patient perseverance in going over 
and over the small ones, that cannot be excised, with the 
electrolytic needle will sometimes greatly lessen them, 
though, of course, we thereby substitute a white cicatricial 
spot for a colored one. The needle should be introduced 
perpendicularly to the skin and deeply, and numerous punc- 
tures arranged in rows thus made. This, of course, is a 
very slow procedure. Powder-grains may be removed by 
Keyes's punch, by making a half turn over them, and then 
snipping off the small piece with the scissors. (Fig. 63.) 



Fig. 63. 



STO H.LMA M N .PFAR R EL&.C0 j! 



O '^4 OF REAL SIZE. 

Keyes's punch. 

Ohmann-Dumesnil 1 recommends thrusting into the stain 
a bunch of six to ten very fine cambric needles tied tightly 
together with silk thread after dipping them into the gly- 

1 New York Med. Joura., 1893, lvii. 544. 



TELANGIECTASIS. 523 

cerole of papoid. In this way the whole tattoo-mark is to 
be gone over. It may have to be gone over a second time. 

Teigne Faveuse. See Favus. 

Teigne Granulee. See Pediculosis. 

Teigne Imbriquee. See Trichophytosis corporis. 

Teigne Pelade. See Alopecia areata. 

Teigne Tondante seu Tonsurante. See Trichophytosis 
capitis. 

Telangiectasis (Te 2 l a 2 n-ji 2 -e 2 k / ta 3 s-i 2 s). This is an ac- 
quired dilatation of the bloodvessels. The condition is well 
seen in rosacea. But it seems to me best to reserve the 
term for those cutaneous lesions in which acquired dilata- 
tion of the bloodvessels of the skin is the only condition 
present. 

Symptoms. The most common form of the disease is 
what is vulgarly called " spider cancer" or ncevus araneus. 
It occurs in nearly all cases upon the cheeks, near the eye- 
lids or bridge of the nose, but may occur anywhere. It is 
usually a single lesion, and consists in a small, central, 
bright-red, slightly raised dot from which radiate fine red 
lines. They sometimes become quite large, though usually 
not more than a half-inch in diameter. This form is seen 
in women and children. It occasionally follows some slight 
injury, but very often seems to come spontaneously. 

Telangiectases in the form of simple dilated bloodvessels 
of varying size and shape are often seen. Under the same 
heading Crocker places those slightly convex or flat, hemp- 
seed-sized, raised, bright crimson, or purplish spots met with 
in old people. Their favorite site is the upper part of the 
trunk, neck, and face. 

Etiology. They sometimes are the result of some slight 
injury as the prick of a pin or a mosquito bite. Sometimes 
they are due to continued congestion of the skin from disease 
of the internal organs. In other cases they result from a 
chronic inflammatory disease of the skin. 

Treatment. The treatment of telangiectasis is simple. 



52-4 DISEASES OF THE SKIN. 

It is only necessary to introduce the electrolytic needle into 
the red central spot, and turn on a current of about two 
milliamperes. The mode of operating is similar to that 
used in destroying superfluous hair, and is described in the 
section on Hypertrichosis. 

Tetter. See Eczema. 

Tinea Amiantacea. See Seborrhoea. 

Tinea Asbestina. See Seborrhoea. 

Tinea Circinata. See Trichophytosis corporis. 

Tinea Cruris. See Trichophytosis corporis. 

Tinea Decalvans. See Alopecia areata. 

Tinea Favosa. See Favus. 

Tinea Furfuracea. See Seborrhoea. 

Tinea Imbricata. See Trichophytosis corporis. 

Tinea Kerion. See Trichophytosis capitis. 

Tinea Nodosa. This is a condition of incrustation of 
the hairs with a fungous growth. The hair follicles are 
unaifected, and the hair is firmly seated in them. The 
hair may be simply incrusted or it may be split. The free 
end of the hair is more affected than the proximal end. The 
spores composing the incrustations are similar to the tricho- 
phyton, but larger. 

Tinea Sycosis. See Trichophytosis barbse. 

Tinea Tondens. See Trichophytosis capitis. 

Tinea Tonsurans. See Trichophytosis capitis. 

Tinea Trichophytina. See Trichophytosis. 

Tinea Versicolor. See Chromophytosis. 

Trichauxis. See Hypertrichosis. 

Trichiasis (Tri'k-r'-a'sr's). This is a congenital or ac- 
quired displacement of the cilise so that they point back- 
ward and scratch the cornea. Both lids of both eyes are 
usually affected. The best treatment is the destruction of 



TRICHOPHYTOSIS CORPORIS. 525 

the hair by means of the electrolytic needle, as described in 
the section upon Hypertrichosis. 

Trichomycose Noueuse. See Piedra. 

Trichomycosis Nodosa. See Leptothrix. 

Trichonosis Cana vel Discolor. See Canities. 

Trichonosis Furfuracea. See Trichophytosis capitis. 

Trichophytie Circinee. See Trichophytosis corporis. 

Trichophytie Sycosique. See Trichophytosis barbae. 

Trichophytosis (Tri 2 k-o 1 -fi 2 t-o / si 2 s). A contagious disease 
of the skin and hair, occurring most often in children, due 
to the invasion of the epidermis by the trichophyton fungus, 
and characterized by the formation of circular or annular 
scaly patches, and partial loss of hair. 

As its name indicates, this is a disease produced by the 
trichophyton fungus. It may find lodgement and growth on 
the general cutaneous surface, in the scalp, beard, or nails — 
that is, in the epidermic structures. In these different local- 
ities it develops so differently as to produce very different 
clinical pictures. We shall describe each one by itself and 
give its differential diagnosis, treating all matters of etiology 
and treatment collectively. 

Trichophytosis Corporis. Synonyms: Tinea circinata ; 
Herpes circinatus ; (Fr.) Herpes circine, Trichophytie cir- 
cinee, (Ger.) Scheerende Flechte ; Ringworm of the body. 

Symptoms. This is the simplest ana most readily cured 
of all the forms of ringworm. It begins as a small, pale- 
red, slightly raised spot, which, growing, spreads out into a 
round, sharply defined, scaly patch ; then it clears up in 
the middle, becomes ring-shaped, and advances with a raised 
border that may be vesicular ; or crusted from the drying of 
the vesicular contents ; or papular and scaly. After a time 
it either ceases to spread, or, enlarging, the edge of the ring 
becomes broken in places. At last it undergoes sponta- 
neous involution. There may be but a single patch, or there 
may be a number of patches. If two circles meet at their 
peripheries, they coalesce and form gyrate figures. Very 

23* 



526 



DISEASES OF THE SKIN. 



often rings do not form, and we have only a round, sharply 
defined, scaly, circular patch. The exposed parts — face, 
hands, and neck — are the most common sites for the erup- 
tion. In rare cases ringworm may be widely disseminated 
over the body. A slight amount of itching is the only sub- 
jective symptom, and that may be wanting. 



Fig. 64. 




Trichophytosis corporis. 
(From Prof. G. H. Fox's service at the Vanderbilt clinic.) 

Another form of ringworm of the body is that known as 
eczema marginatum, which is ringworm located in the crotch 
or axilla. It is usually of a more highly inflammatory charac- 
ter than the same disease on other parts of the body, and re- 
sembles an eczema very closely — in fact, it is often compli- 
cated by an eczema. The edge of the patch is sharply 
defined, raised, scalloped, papular, and scaly, while the 
center may be smooth, or pigmented and crusted. The 
patch often attains large dimensions, running down the inside 



TRICHOPHYTOSIS CORPORIS. 527 

of the thigh, up over the abdomen, and backward over the 
perineum. Usually the inside of both thighs is affected. 
There is considerable itching. The same symptoms are 
presented when the axillae are affected. There is also a true 
eczema of the crotch that is not due to the trichophyton, 
but resembles the form just described. 

Tinea imbrieata is supposed to be a very aggravated form 
of body ringworm occurring in tropical countries. But 
Manson 1 says that it differs from ordinary ringworm in 
affecting a very large part of the body at the same time ; 
in avoiding hairy parts, and sparing the hair; in an ab- 
sence of signs of inflammation ; in not forming a single 
ring, but ring within ring, and recurring in parts gone 
over; in having large abundant scales ; in profuse fungous 
growth ; in always breeding true in inoculation-experi- 
ments ; and in occurring only in certain parts of the world. 

Diagnosis. Trichophytosis corporis is readily diagnosed, 
as its appearance is distinctive. Favus of the body may 
spread out into a circular patch, but soon it will show the 
distinctive sulphur-yellow cupped crusts. Psoriasis on the 
body will have a brighter red color ; its scales will be more 
abundant, thicker and brighter ; it will be found on the tips 
of the elbows and over the knees, and will be more profuse 
and disseminated ; and examination of the scales will show 
an absence of fungus. The scaling papular sypMlide or the 
squamous syphilide will not itch ; there will be no fungus in 
the scales ; the color will be raw-ham ; the base will be 
more infiltrated ; it will run a more chronic course ; and 
will not yield so readily to treatment. Seborrhoea of the 
chest may occur in rings, but its location will suggest its 
origin ; the skin will be greasy, the scales will rub off easily, 
and there is no fungus in them. Eczema of the crotch or 
axilla differs from ringworm of the same region in not having 
a so sharply defined and scalloped or festooned border; in 
forming a more evenly diseased patch with no sound skin in 
it ; and in having no fungus in the scales taken from it. 
Pityriasis rosea is more widely distributed than is ringworm, 

1 Brit. Journ. of Dermatol., 1892, iv. 5. 



528 DJSEASES OF THE SKIN. 

and spreads more rapidly : it is not so scaly ; has a more 
yellowish center; is usually most abundant on the trunk ; 
shows no fungus under the microscope ; and the eruption is 
made up of both macules and rings. 

Trichophytosis Capitis. Synonyms i 1 Herpes tonsurans 
seu circinatus, seu squamosus; Tinea tonsurans, seu ton- 
dens ; Porrigo furfurans ; Dermatomykosis tonsurans (Kob- 
ner) ; (Fr.) Herpes tonsurante, Teigne tondante ou tonsur- 
ante, L'herpes circine parasitaire ; (Grer.) Scheerende 
Flechte ; (Slav) Ringskurv ; Ringworm of the scalp. 

Symptoms. This form of ringworm is seen almost exclu- 
sively in infants and children. As puberty or early adult 
life is reached the disease, no matter how long continued, and 
how severe it may be, tends to get well of itself. It begins 
as a single vesicle or a small, insignificant, red, scaly spot 
that would pass without suspicion of its nature unless other 
cases of ringworm put us on our guard. From this small 
beginning the disease spreads peripherally to form a circular 
patch, which is red, covered with grayish scales, sharply 
defined, perhaps slightly elevated, and partially bald. In- 
spection of the patch will show a number of broken-off 
stumps of hair with split ends. These stumps are char- 
acteristic of the disease. The hair growing in and about the 
patch is dry, lustreless, split; and brittle. Attempts at 
epilation break it off, and if it is indented with the finger- 
nail it will take a sharp angle and retain it. This shows 
that it has lost its resiliency. Apparently healthy hairs are 
sometimes growing from the patch. The size of the patch 
varies greatly. It may be no larger than that of a ten-cent 
piece, or it may be so large as to denude a good part of the 
scalp. These large patches are usually formed by the 
coalescence of several small ones, and then they lose their 
circular outline and become scalloped. There may be but a 
single patch, or there may be a number of them. After 
attaining the size of a half-inch to one inch in diameter, the 
patches may remain stationary in size, or increase slowly. 

1 I can mention here only the more common ones, as their number 
is legion. 



TRICHOPHYTOSIS CAPITIS. 529 

The most frequent sites are the vertex and parietal regions. 
Pruritus of greater or less degree is usually complained of, 
and it may be the first symptom that draws attention to the 
child's scalp. The course of the disease is exceedingly 
chronic. It does not produce permanent baldness. 

Fig. 65. 





Trichophytosis capitis. 
(From Prof. G. H. Fox's service at the Vanderbilt clinic.) 

This is the typical " ringworm," as seen in the vast ma- 
jority of cases. Sometimes, instead of being scarcely or 
not at all raised above the surface of the skin, the patch, 
usually a single one, begins to swell up, becomes raised, un- 
even, and boggy, and we have the condition of things de- 
scribed as kerion (which see). Another variety is what 
Liveing terms bald tinea tonsurans. This begins as an 
ordinary ringworm, but after a time the hair all falls out, 
the scalp is smooth and without scales, as in alopecia areata, 
and at its boder there may be found short broken hairs, 
like those seen in the latter disease. At first this change 
takes place in one patch alone, and we will be guided to a 
right diagnosis of the disease by the appearances of the 
other patches. Later, these too become altered, and then it 
would be hard to make the diagnosis without the history of 
their having been scaly patches. This is an infrequent form 
of the disease. 

Still another form is called disseminated ringworm. 



530 DISEASES OF THE SKJJS 7 . 

Here the patchy, areated character of the disease has disap- 
peared, the hair has apparently grown in nicely, and there 
is seemingly only a scurvy condition of the scalp. This is 
a dangerous form, because the child is often regarded as well, 
and yet is quite capable of spreading infection. Careful 
examination of the case, by causing the child to stand with 
his back to the physician, and turning the hair slowly back- 
ward against its direction of growth, will show here and 
there " stumps," and also the presence of hairs that stand up 
from the head for a few moments. Normal hair falls quickly 
back into place, which is not the case with hair affected with 
ringworm. 

A pustular form is sometimes described. It is simply a 
ringworm occurring in a strumous subject, in whom all in- 
flammatory skin diseases are prone to assume a pustular 
character. 

Diagnosis. Trichophytosis capitis must be differentiated 
from alopecia areata, favus, eczema, seborrhoea, and psori- 
asis. From alopecia areata it differs in being scaly ; in not 
producing perfectly bald patches ; in its much slower prog- 
ress ; in the presence of " stumps ; and in having the 
trichophyton fungus in the hair, as seen under the micro- 
scope. From favus it differs in the absence of the sulphur- 
yellow cupped crusts of that disease ; in not having such 
heaped-up asbestos-like crusts; in forming distinct round 
patches ; in the more brittle character of its hair ; in not 
producing red, smooth, permanently bald spots that later 
become white and cicatricial, and in showing a marked ten- 
dency to get well of itself as puberty is reached. The diag- 
nosis between them by the microscope is not easy without a 
knowledge of the appearances on the skin. The spores of 
favus are more polymorphous and somewhat larger than 
those of trichophytosis, and its mycelia are more abundant 
than its spores. From eczema it differs in the more cir- 
cumscribed and circular character of its patches ; in being 
less itchy, and in the presence of broken-off hairs and 
stumps. The presence of these broken-off hairs and 
stumps, and of the fungus in the hair and scales, will 
sufficiently distinguish ringworm from both seborrhoea and 
psoriasis. 



TRICHOPHYTOSIS BAEBM 



531 



Trichophytosis Barbae. Synonyms : Tinea sycosis, seu 
barbae ; Sycosis parasitaria, seu parasitica ; Herpes ton- 
surans barbae ; (Fr.) Trichophytie sycosique, Sycosis para- 
sitaire ; (Gr.) Parasitische Bartfinne ; (It.) Sicosi para- 
sitaria ; (Eng.) Barber's itch, Ringworm of the beard. 

When the trichophyton invades the beard, at first it forms 
simply a superficial scaly circular patch which increases in 
size, just as on the scalp, producing broken-off hairs and a 

Fig. 66. 




Trichophytosis barbte. 
(From Prof. G. H. Fox's service at the Vanderbilt clinic ) 

partially bald area. There are usually several of these areas 
upon the chin and cheeks. If not checked by treatment, we 
have the more characteristic development of the disease, in 
which there will be either some pustules, pierced by hairs, or 
else a group of large nodular swellings, varying in size from 
a split-pea to a half-cherry, arranged in the form of a circle. 



532 DISEASES OF THE SKIN. 

There are usually several groups of them. The nodules are 
prominently raised and usually rounded. (Fig. 66.) They 
are of a congested red or purple color. They may be 
hard and scaly ; or give exit to a sticky discharge ; or, 
rarely, suppurate. The hair over them is broken, or more 
or less wanting. Usually itching and burning are com- 
plained of. 

Diagnosis. The disease is to be differentiated from 
sycosis, pustular eczema, and the tubercular syphilide. From 
sycosis it differs in affecting the lower part of the face and 
sparing the upper lip ; in presenting broken-off hair ; in 
having grouped nodules ; and in the presence of the fungus 
in the hair. Sycosis is more acute in its manifestations, 
and is characterized by its many discrete pustules pierced 
by hair. From eczema it differs in the same points as it 
does from sycosis and also in being less crusted, and in the 
ease with which the hair can be plucked or will break. 
Eczema is also a disease of the skin and not of the hair. The 
tubercular syphilide does bear a resemblance to trichophy- 
tosis barba3 at times. It differs in forming but a single 
group, in being of a darker color, and in undergoing a 
steady course of development toward final recovery, leaving, 
not infrequently, permanent scars. Other symptoms of 
syphilis will often be found, and its whole history will be 
different. 

Trichophytosis unguium, or onycho-mycosis, is ringworm 
as it affects the nails. It begins as a change in color of the 
nail-substance and with a loss of its transparency. The nail 
becomes uneven and thickened, and its edge, which is usu- 
ally the part first attacked, becomes raised from its bed by 
an accumulation of scaly matter under it. A progressive 
atrophy takes place, and at last the nail breaks and falls 
either in part or as a whole. There may be but one nail 
affected, or all the nails both of the hands and feet may be 
attacked, then usually consecutively. 

Diagnosis. The appearances presented by the nails are 
so similar to those seen in psoriasis, and other diseases in 
which the nails become atrophied, that a positive diagnosis 



TRICHOPHYTOSIS. 533 

can be made by the microscope alone, unless there should 
be symptoms of the one or the other disease present else- 
where on the body as a guide. 

Having now described the different varieties of ringworm 
with their differential diagnosis, we pass on to study the 
factors common to all. 

Etiology. The cause of the disease is contagion with 
the trichophyton fungus. This contagion may be direct, 
from person to person, or indirect by means of brushes, 
towels, clothing, and the like. It is possible that the air 
may become so full of the fungus in epidemics in crowded 
children's asylums that contagion may be by means of the 
fungus lighting upon the head or body. The disease is 
very contagious, much more so than is favus. 

As the disease is quite common in dogs, cats, and horses, 
constituting in them one form of mange, they form a very 
frequent source of contagion. Ringworm of the scalp is 
often communicated by means of brushes and headgear. 
Ringworm of the beard is conveyed by means of brushes, 
towels, and the barber's fingers. Ringworm of the nail 
comes from scratching. Some skins seem to furnish a 
better soil for the growth of the fungus than do others. 
Children have ringworm of the scalp ; adults almost never. 
There is no peculiarity of constitution that predisposes to 
the disease. It attacks all classes and conditions of society, 
though, of course, it is most common among the crowded 
poor. 

Pathology. The trichophyton tonsurans, the fungus of 
ringworm, has it habitat in the epidermic structures of 
the skin. On the general cutaneous surface it is so super- 
ficially located as to be readily destroyed. When it attacks 
the hair and nails it penetrates below the skin in their epi- 
dermic structures, and is much more difficult of cure. 

The exact botanical position of the fungus is not yet deter- 
mined, but there is no doubt that it is a special form of 
fungus. (Fig. 67.) It consists in mycelia and conidia 
(spores), the proportion of which to each other varies ; in the 
hair of the scalp and beard the number of spores far exceeds 



534 



DISEASES OF THE SKIN 



that of the mycelia. Sometimes they are so numerous as to 
be crowded together in lines. On the general surface the 
mycelia are far more numerous. They are long, slender, 
branched, straight, or crooked bodies. The spores are 
round, small, and refract light. Having become lodged in 
the skin the fungus always sets up a certain amount of irri- 
tation by its processes of growth. If it lands upon hairy 



Fig. 67. 




Trichophyton tonsurans in hair shaft and follicle. (After Kaposi.) 



regions, it attacks the hair secondarily, passing down the walls 
of the hair follicle to a greater or less depth before it pene- 
trates the cuticle of the hair and gains access to its sub- 
stance. Having gained access, it vegetates freely and may 
often be traced throughout the whole length of the hair. 
Robinson and others have found the fungus in the peri-follic- 
ular tissue. Its presence always causes more or less peri- 
folliculitis, and this is much more intense in the beard than 
in the scalp hair, which, together with the looseness of the 
subcutaneous connective tissue in the beard, will explain the 



TRICHOPHYTOSIS. 535 

reason why we have the nodules form there. If the peri-fol- 
liculitis is very great, permanent baldness may result. In 
trichophytosis unguium the fungus grows in the substance of 
the nails. By Sabouraud it is taught that there are various 
varieties of trichophyton. In the human two main varie- 
ties are found, one of which has small spores and the other 
large spores. The former causes the obstinate cases of ring- 
worm on infants' scalps, while the latter gives rise to the 
easily cured cases of ringworm of the scalp, and is the com- 
mon cause of trichophytosis barbae et corporis. 

Treatment. There is no disease of the skin much more 
easy of cure than trichophytosis of the general surface of 
the skin, and none much more difficult of cure than tricho- 
phytosis capitis. 

Tricophytosis corporis may be readily cured with almost 
any slightly irritating and astringent application, and by all 
the antiparasitics. The old women cure it by means of 
common ink, or by using vinegar in which a copper coin 
has been soaked. We can direct that the scales be removed 
with soap and water, and an ointment of sulphur, or am- 
moniate of mercury, or chrysarobin, or pyrogallol be applied, 
or simply paint the patch with tincture of iodine, acetic or 
sulphurous acid, or a solution of bichloride of mercury, three 
to five grains to the ounce. The last is a good method for 
adults as it does not stain the skin, and one application will 
usually cure the disease. It is rather too strong for chil- 
dren. Other applications are a saturated solution of hypo- 
sulphite of soda ; oleate of copper, half a drachm to the 
ounce of ointment ; and salicylic acid, 5 or 10 per cent, 
strength, which by no means exhausts the list. 

Trichophytosis cruris et axillce is not so easy to cure as 
the preceding variety, but it can be cured by any of the 
means detailed above. In using chrysarobin, here as else- 
where, we should bear in mind its irritant qualities. Taylor 
has recommended painting the parts with two to four grains 
of bichloride of mercury in one ounce of tincture of benzoin. 
Hardaway speaks well of modified Wilkinson's ointment. 
Some cases will make a good recovery under an ointment 
containing oil of cade, one drachm to the ounce. This is 



536 DISEASES OF THE SKIN. 

specially useful after the use of sulphur or other antipara- 
sitic to kill the fungus, as it is curative of the eczema that 
often remains. 

Trichophytosis capitis is the most obstinate form of ring- 
worm to cure. The fungus is present abundantly deep 
down in the skin, and each hair is a separate focus of dis- 
ease. The difficulty we have to contend against is to cause 
our remedies to enter the skin deeply enough to destroy the 
fungus. Nature gives us a hint as to the cure of the disease 
when a kerion forms that is not infrequently followed by 
disappearance of the disease. Most of the co-called reme- 
dies for ringworm are irritants to the skin, and do good quite 
as much by the irritation they cause as by their parasiticide 
properties. 

If we see the case at its earliest stage, we may sometimes 
succeed in aborting the disease by the application of the 
bichloride of mercury, five or ten grains to the ounce. 
Usually, when the case is brought to us, it has gone too 
far for aborting it. Then we may sometimes cure the case 
promptly, but most often it is an affair of months and, per- 
haps, years. The first requisite for a cure is faith on the 
part of the patient, so that the second element, persistency, 
can come into play ; and then by the persevering use of 
parasiticides a cure may be effected. As each case is a 
source of contagion, steps must be taken to isolate the case 
if it occur in an asylum or school. If it occur outside of an 
institution, the parents must be cautioned not to allow the 
child's hat or clothing to be worn by any other child, and 
the child must be taken out of school. To assure still fur- 
ther the safety of others, an antiparasitic must be applied 
to the child's head, such as a 1 or 2 per cent, solution of 
salicylic acid in alcohol and castor oil. The child should 
also wear a linen cap over the whole head. These regula- 
tions are difficult to carry out in private practice. 

The ringworm patch or patches should be scrubbed with 
soap and water so as to remove all the scales before we make 
any local application. Tar soap is a good one to use for the 
purpose. Then the hair should either be cut short, pulled 
from, or shaved off the patches and for about a quarter of 



TRICHOPHYTOSIS. 537 

an inch about them. Now the case is ready for the chosen 
parasiticide. Whatever is used in the form of an ointment 
or oil should not be smeared over the surface, but it should 
be worked in, as it were. The remedies we use are ex- 
hibited in the form of ointments, oils, varnishes, pastes, 
solutions, and plasters. It is, unfortunately, necessary to 
give a lengthy list of remedies from which the reader may 
select. One of the oldest and most used of them is the offic- 
inal sulphur ointment, full strength or diluted according to 
reaction. No pustulation should be caused by our applica- 
tions. Here, as elsewhere, when an ointment is mentioned, 
it is to be understood that it may be made with lard, vaseline, 
lanolin softened with oil, or plasment (mucilage of Irish moss). 
The last is to be preferred because it is not greasy, sinks 
readily into the skin, and leaves a slight film over the patches 
that prevents, to a certain extent, the escape of the spores 
into the air. The persistent daily use of sulphur ointment, 
combined with epilation, and scrubbing of the patch with 
soap and water about once a week, will cure the disease. 
Sulphur may also be used in combination with other drugs. 
As nothing has yet been found to render it soluble in any 
amount, it must always be exhibited in ointment or paste 
form. Mercury is another old stand-by. It may be used 
as a solution of the bichloride in alcohol (grs. j-iij ad §j), 
whose application should not be intrusted to anyone but a 
physician or trained nurse. It is to be used two or three 
times a day, its effect carefully watched, and, of course, it 
should not be used to large surfaces. It may be employed 
as recommended by Kerley, 1 who reports having cured a 
number of cases in from two to twenty weeks by using a 
solution made by adding two grains of the bichloride dis- 
solved in sufficient alcohol to a half-ounce each of kerosene 
and olive oil, daily rubbed into patches as well as applied all 
over the scalp. When inflammation is caused, the applica- 
tion is stopped, and a simple ointment is used until the irri- 
tation subsides. Then the bichloride is again applied. The 
scalp is to be washed often. He thinks that a cure will be 

1 N. Y. Med. Journ., 1891, liv. 396. 



538 DISEASES OF THE SKIJS 

hastened by using a saturated solution of iodine on alternate 
days with a bichloride solution. Crocker thinks highly 
of the bichloride, three grains dissolved in alcohol, to the 
ounce of turpentine. Tincture of benzoin is a good ex- 
cipient for the bichloride, according to Leviseur, 1 who recom- 
mends the application of it, 1 to 2 parts of Hg to 300 parts 
of benzoin, once a week, with the daily use of salicylic acid 
ointment in 10 to 20 per cent, strength. All the mercurial 
ointments are useful, but are not so prompt in their action 
as other remedies. 

The remedies recommended in the treatment of ringworm 
of the body are all of use in the same disease of the scalp, 
and need not be repeated here. The main modification is the 
epilation that should precede their application. Instead of 
using tincture of iodine, the English authors commend Cos- 
ter's paints, made of two drachms of iodine and six drachms 
of the light oil of wood-tar, which is to be firmly applied with 
a stiff brush. A black crust will form after two or three 
days, which should be removed with the forceps. The part 
should then be washed with soap and water, and the paint 
again applied. Two or three applications may be made of 
it to an infant's scalp, or it may be continued longer in chil- 
dren over four years of age. 

Chrysarobin in 10 per cent, strength in traumaticin or 
collodion is good, its tendency to produce dermatitis being 
ever borne in mind. Pyrogallol in 5 to 15 per cent, in the 
same excipients, with or without the addition of half a 
drachm of salicylic acid to the ounce, is a reliable prepa- 
ration, fl-naphthol or hydronaphthol are commendable. 
One of the neatest methods for treating ringworm is that 
commended by Dockrell, 2 and it has proved useful in my 
hands. He directs that after shaving and washing the head 
with a 5 per cent, hydronaphthol soap and hot water, the 
part is to be dried and covered with strips of 10 per cent, 
hydronaphthol plaster so that they overlap at the edge. Over 
all is to be poured some melted 10 per cent, hydronaphthol 
jelly. At the end of four days the plaster is to be re- 

1 Med. Eec , 1889, xxxv. 594. 2 Lancet, 1889, ii. 1110. 



TRICHOPHYTOSIS. 539 

moved, the head again washed, and a 20 per cent, plaster 
applied and worn for one week. Finally a 10 per cent, 
plaster is to be worn for ten days. If not well then, the 
process may be repeated. Naphthol may be used as a 1 per 
cent, solution in alcohol, or in the form of a paste, as recom- 
mended by Kaposi •} 

R. Naphthol, 1 

Spt. sap. viridis, 2 

Alcohol, 50 

Bals. peruv , 2 

Sulph loti, 10 M. 

Either may be applied twice a day for two or three days, 
and then followed by thorough scrubbing with green soap. 
Thymol in 5 to 10 per cent, strength, dissolved in chloro- 
form and olive oil, is recommended by Malcolm Morris. 

Harrison 2 endeavored to effect entrance of his remedies 
to the deeper parts of the skin by first applying to the scalp 
solution No. 1, composed of half a drachm of potassium 
iodide in one ounce of liquor potassae. After a few days he 
applied solution No. 2, composed of three grains of corro- 
sive sublimate to one ounce of sweet spirits of nitre, or of 
water. This treatment requires careful watching. Foulis 3 
recommends rubbing turpentine into the scalp, after cutting 
the hair, until it smarts. Then it is to be scrubbed with 10 
per cent, carbolic soap, dried, and painted with two or three 
coats of tincture of iodine. When dry the whole head is to 
be anointed with carbolized oil, 1 in 20. This procedure is 
to be carried out once a day. Alder Smith has found useful 
a saturated solution of boric acid, as follows : 

R. Ac. boric, £iv; 15 

iEtheris, % v ; 150 

Alcoholis, ad Jxx; 600 M. 

It is to be freely applied after washing the head in the 
morning, and two to five times during the day. 

1 Wien. med. Woch., 1881, xxxi. 617. 

2 Brit. Med. Journ., 1885, ii. 134. 

3 Ibid., 1885, i. 536. 



540 DISEASES OF THE SKIN. 

In very chronic cases and in the disseminated form it may 
be necessary to blister the patch by means of croton oil or 
acetic acid. Croton oil must always be used with caution 
and to small areas, as it is capable of producing permanent 
baldness. One part in ten of olive oil is usually sufficient, 
but the strength may be increased till we have it sufficiently 
strong to cause a mild degree of pustulation, when the hairs 
may be easily plucked. In disseminated ringworm a drop 
of the pure oil may be applied to each diseased follicle, and 
as soon as a pustule forms the hair should be pulled out. 
In very obstinate cases electrolysis may be practised to indi- 
vidual hairs, which, like the croton oil, will permanently de- 
stroy the hair. 

Epilation is of positive value in treating this obstinate 
disease, even though the hair does break off. Some hair 
with its fungus will come out, and the follicular mouths will 
be rendered more open for the entrance of our applications, 
which should always follow epilation. Besnier epilates 
around the patches, and asserts that then the disease rarely 
spreads to neighboring parts. 

Treatment should be continued until there are no more 
stumps or broken-off hairs to be seen ; till the microscope 
fails to reveal any fungus in the hair after prolonged search, 
and until the scalp is no more scaly. It is well to use the 
following : 



R. Hydrarg. ammon., 9j ; 3 

Hydrarg. chlor. mitis, j}ij ; 7 

Vaselini, %] ; 30 



75 
50 
00 M. 



or a sulphur ointment for several months after apparent 
cure. 

Trichophytosis barbce is treated along the same lines as 
when the scalp is the seat of the disease. The beard should 
not be shaved, but cut short with scissors. Here epilation 
is of more positive value, as the hairs over the nodules will 
come out easily. It is possible to abort the disease before it 
has implicated the hair by the application of a solution of 
five to ten grains of bichloride of mercury in alcohol. A 10 
per cent, solution of resorcin or an ointment of the same 



TUBERCULE ANATOMIQUE. 541 

strength may accomplish the same end. After the disease 
has got under full way, systematic epilation, daily shaving 
by the patient himself, and the thorough application of one 
of the parasiticide preparations mentioned in the preceding 
section will effect a cure. 

Trichophytosis unguium may be treated by producing a 
paronychia. This may be done by Pellizzari's 1 method of 
keeping green soap upon the nail under a rubber cot for a 
few days, until the nail is softened. Then equal parts of 
olive oil and pyrogallic acid are to be applied till the nail 
loosens, when it is to be removed and the finger dressed with 
iodoform. Thin 2 recommends scraping the affected nails 
very thin, applying liquor potassse to soften them, and then 
dabbing on creosote, or acetic acid, or a solution of two to 
five grains of bichloride of mercury, in alcohol. Crocker 
speaks well of using Harrison's plan for treating ringworm 
of the scalp, which see. Solution No. 1 should be applied 
after scraping and kept on for fifteen minutes, covered with 
oiled silk ; then No. 2 applied in the same way and kept on 
for twenty-four hours. These should be repeated till the 
cure is effected. If the skin should become tender or begin 
to peel, the solutions should be stopped, and one of hypo- 
sulphite of soda used until the skin heals. 

Prognosis. All forms of ringworm, excepting that of 
the general surface of the body, are very obstinate, but 
persevering and intelligent treatment will cure them all. 
The most obstinate form is that of the scalp, and a speedy 
cure should never be promised. 

Trichoptilosis. See Atrophia pilorum propria. 

Trichorrhexis Nodosa. See Atrophia pilorum propria. 

Trichoxerosis. See Atrophia pilorum propria. 

Tubercula Miliaria. See Milium. 

Tubercula Sebacea. See Milium. 

Tubercule Anatomique. See Tuberculosis verrucosa cutis. 

1 Giorn. Ital. d. Mai. Ven. e del Pelle, March, 1888. 

2 The Practitioner, May, 1887, etseq. 

24 



542 DISEASES OF THE SKIN. 

Tuberculosis Cutis. Symptoms. This is a rare disease, 
having been met with by Chiari but five times in between 3000 
and 4000 post-mortems of those who had died of tubercu- 
losis. It occurs almost exclusively about the mucous orifices 
— mouth, anus, vulva, and glans penis. Crocker describes 
the disease as follows : u The lesions consist of one or more 
discrete, shallow, not painful ulcers, which form apparently 
spontaneously, have an irregular, eroded, moderately infil- 
trated edge, and when the crusts, which soon cover them, 
are removed, show a reddish-yellow, granular surface, with 
a thin, scanty secretion. They never heal, but spread slowly 
and continuously, and may coalesce with neighboring ulcers, 
becoming serpiginous ; they may thus extend over an area 
of one or more square inches; but, as a rule, they are small. 
When on mucous membranes, yellow miliary papules exist 
near them." They are due to local infection with the tubercle 
bacillus, and are a part of a general tuberculosis. Their 
diagnosis is difficult, though their nature may be suspected 
on account of the other and evident symptoms of the primary 
disease. 

Treatment. Treatment is unavailing, though iodol, 
iodoform, or aristol may be applied. 

Tuberculosis Verrucosa Cutis. Synonyms : Verruca 
necrogenica ; Lupus verrucosus ; Scrofuloderma verrucosum ; 
(Fr.) Lupus sclereux, ou 1. papillaire verruqueux ; Anatomi- 
cal tubercle ; Post-mortem warts. 

These names have been given by different writers to what 
may be regarded^ as simply varying aspects of the disease 
described by Riehl and Paltauf 1 as tuberculosis verrucosa 
cutis. It is one of the rare skin diseases, but not so very 
infrequent as statistics would show. It was met with four 
times in 3726 cases in Professor Fox's service at the Van- 
derbilt clinic in 1892. 

Symptoms. 2 The disease occurs usually in the form of a 
single round or oval patch. There may be several such 

1 Vierteljahr. f. Derm. u. Syph,, 1886, xiii. 19. 

2 The description here given is taken, for the most part, from the 
above-mentioned article by Riehl and Paltauf. 



TUBERCULOSIS VERRUCOSA CUTIS 



543 



patches. If two patches join, irregularly shaped patches, 
with scalloped border, may form, and perhaps become ser- 
piginous. In size the single patches vary from that of a 
lentil up to that of a silver half-dollar. Around the patch 
is a narrow zone of erythema, of a bright-red, that disap- 
pears under pressure. Its surface is smooth, and often more 
shiny than the normal skin. Toward the next zone it is 
slightly elevated. Its follicular openings are preserved. 



Fig. 




Tuberculosis verrucosa cutis. { After Hyde.) 



Inside of this zone is a row of small, discrete, superficial 
pustules, whose covers are so thin that they break easily, 
and we find only the crusts and scales left by them. The 
color of this zone is brown or livid red, and it cannot be 
pressed out entirely, showing that there is some infiltration 
of the skin. This zone is slightly raised, but the one to its 
inner side is markedly so. It has also an irregularly knobby 
surface, becoming distinctly warty toward the center of the 
growth, the warts being rounded or pointed. The nearer 
the center the warts are the larger they are, some of them 
being 5 to 7 mm. long. The whole surface of this zone is 



544 DISEASES OF THE SKIN. 

more or less scaly or crusted. The color is brownish-red. 
The warty growths are often close together with fissures 
between them, and little erosions and pustules. If the 
patch is pinched up between the fingers, little drops of pus 
may be made to well up from between the papillae. The 
mouths of the follicles are destroyed. In some cases acute 
inflammation may occur, and then the patch will swell up 
and become more angry-looking. 

After a time the patch begins to flatten in the middle by 
the disappearance of the warty growths, and at last becomes 
changed into a smooth or slightly scaling cicatrix, which is 
thin and soft, with a delicate sieve or net-like appearance. 

The patch is always freely movable upon the underlying 
parts, and usually gives rise to no subjective symptoms. 
Sometimes pain is complained of on pressure. The growth 
is by the addition of new lesions on the periphery of the old 
patch, and is usually very slow, and at intervals with pauses 
between. It is a chronic affection, showing no tendency to 
spontaneous recovery. 

Such is the typical disease and its course. In the de- 
scriptions of the different diseases named above will be found 
some deviations from the type, but they all agree in the 
main, and are probably all one and the same disease. It is 
met with most often upon the backs of the hands and fingers, 
but may occur anywhere. 

Etiology. The cause of this form of tuberculosis is the 
inoculation of the skin with the tubercle bacillus, which has 
been found in sections taken from the patches. The disease 
is seen most frequently in men, and is specially prevalent in 
butchers and those who have to do with animals. Dead-house 
attendants are also its victims not infrequently. Cases have 
been directly traced to inoculation with tubercular tissue. 

Diagnosis. Though allied to lupus, it differs from it by 
the entire absence of the characteristic lupus tubercles, and 
of the tendency to ulceration ; by the manner of healing in 
the center by a scar in which no relapse takes place; by its 
superficial situation in the skin ; by the purulent matter 
that can be squeezed out from between its papillae ; and by 
the relatively late time of life in which it appears. From 



ULCERS. 545 

syphilis it differs in its more chronic course ; in the absence 
of a wall of infiltration about it ; in its color ; and in show- 
ing no tendency to break down and ulcerate. 

Treatment. The growth may be curetted away, and 
the wound afterward treated with pyrogallol, as in lupus. 
Or it may be destroyed by the galvano-cautery, or by elec- 
trolysis. Or it may be covered with a twenty-five per cent, 
salicylic acid creosote plaster. Crocker advises the use of 
this plaster, to be followed with the fuming nitrate of mer- 
cury applied with a piece of wood. I have found the plaster 
sufficient in itself. Or it may be destroyed by any power- 
ful caustic, but it must be destroyed entirely or it will crop 
out again. 

Prognosis. The disease is more easily curable than is 
lupus, and, as a rule, the growths are readily removed. 

Tumeurs Folliculeuses. See Molluscum sebaceum. 
Tumores Sebiparis. See Molluscum sebaceum. 
Tyloma. See Keratosis palmaris et plantaris. 
Tylosis. See Keratosis palmaris et plantaris. 
Tylosis Linguae. See Leucoplakia. 

Ulcers. Ulceration is a symptom common to many dis- 
eases such as lupus, syphilis, scrofulodermata, and other 
destructive processes. For these the reader is referred to 
the sections treating of the diseases of which they form a 
part. We shall here deal briefly with those ulcers of the 
leg that form so large a part of every dermatological clinic, 
and that are usually called varicose ulcers. They are lo- 
cated most often over the anterior surface of the leg and on 
its lower half. They may be superficial or deep. They are 
irregular in shape with sloping or undermined edges, and 
with a more or less wide zone of redness and infiltration of 
the skin about them. Their bases may be covered with 
flabby granulations ; or smooth and glazed, with thin, scanty 
secretion ; or they may discharge a great deal of sero-puru- 
lent matter. Some of them bleed readily, some do not. 
There may be but one ulcer, or there may be several of 



546 DISEASES OF THE SKIN. 

theui. One or both legs may be affected. The ulcer may be 
small, or so large as to encircle the leg and occupy more 
than half its length, and it may attain this size either by 
gradual extension of itself, or by the junction of several 
ulcers. They begin not infrequently as a number of small 
shelving ulcers on a red and densely infiltrated base. These 
enlarge rapidly and form a large ulcer. The patient com- 
plains of more or less spontaneous pain, and the ulcers are 
often very tender. The foot and leg are sometimes greatly 
swollen and feel brawny. It will be noted that the foot and 
leg are marked with dilated veins, and varicosities can be 
felt sometimes like whip-cords under the skin. The deep 
veins are generally swollen at the same time, though they 
cannot be felt so readily. Usually both legs are affected. 

Etiology. These ulcers are predisposed to by standing 
for hours at a time, and it is standing in one position that is 
particularly obnoxious. It is therefore in car-drivers, black- 
smiths, cooks, and those following similar occupations that 
ulcerations are prone to occur. A loaded condition of the 
portal circulation and constipated bowels also favor vari- 
cosities and the occurrence of ulceration. On account of the 
chronic, congested condition of the leg, some slight trauma- 
tism that in the normal state would produce a hardly appre- 
ciable damage will be followed by a breaking down of the 
tissues and an ulcer. 

Diagnosis. It is most important to diagnose a varicose 
ulcer from one due to syphilis, as they require different treat- 
ment, and have a different prognosis. The syphilitic ulcer 
is usually located upon the upper half of the leg, and toward 
its posterior surface, or about the knee. It has an infiltrated 
border, but by no means as broad a one as the varicose 
ulcer. It lacks the marked inflammatory symptoms of the 
varicose ulcer, and is " punched-out looking" with perpen- 
dicular edges. It is round, or, if formed by the coalition of 
several softened tubercles, it will have a scalloped edge, indi- 
cating its origin from several distinct lesions. As a rule, it 
is quite painless, and there are several ulcers on one leg, the 
other being free. 

Treatment. If we can confine our patient absolutely to 



ULCERS 547 

bed, and keep the leg snugly and evenly bandanged, the ulcers 
will heal under simple dressings. This we cannot do with 
most of our cases. Bandaging the leg from the toes to the 
knee is an essential in their successful management, an ordi- 
nary roller-bandage being used as long as any greasy appli- 
cations are made. In ulcers connected with varicose veins, 
after acute symptoms have subsided, bandaging from the 
toes to knee with a rubber bandage is excellent. So too in 
all ulcers is the continuous batli with warm water, or by 
means of cloths wrung out of hot water, frequently renewed 
and covered with oiled silk. 

One of the oldest and best treatments for ulcers is to touch 
them daily with balsam of Peru and cover them with oxide 
of zinc ointment, or, better, with Lassar's paste. Dry 
dressings for the ulcer are preferable to greasy applica- 
tions, and for this we may use iodoform, iodol, aristol, sub- 
nitrate or subiodode of bismuth, or dermatol, one of the 
latest remedies. If there is any eczema or dermatitis about 
the ulcer, it is requisite to cover the powder and the whole 
patch with some mild or stioiulating ointment according to 
the state of the skin. In this case the ulcer must be dressed 
once or twice a day. If there is not much dermatitis, we 
can dispense with the ointment and do the leg up antisepti- 
cally and leave it for several days. Applications of nitrate 
of silver may be used to stimulate an atonic ulcer or to 
smooth down exuberant granulations. Strapping with ad- 
hesive plaster is another excellent means in ulcers upon not 
very much inflamed bases. Skin-grafting, according to 
Thiersch's method, is the most prompt and sometimes the 
only way to cause large ulcers to heal. For further surgi- 
cal treatment of ulcers text-books on surgery must be con- 
sulted. 

Ulcer, Perforating, of Foot. See Perforating ulcer of foot. 

Ulcer, Tropical Phagedenic. This is an ulcer second- 
ary to a lesion of the skin that occurs in the tropics, and 
is marked by rapid extension and gangrenous destruction 
of tissues. It may be mild or malignant in its course. The 
latter eats deeply, even involving the bones. 



548 DISEASES OF THE SKIN. 

Ulcus Rodens. See Epithelioma. 

Ulcus Grave. See Fungous foot of India. 

Ulerythema (U 2 l-e 2 r-i 2 -the r ma 3 ). This is the name pro- 
posed by Unna for those diseases in which there is a more or 
less persistent erythema upon which follows cicatrization by 
a process of absorption of inflammatory infiltration, and 
without ulceration. Under this heading comes lupus ery- 
thematosus. Ulerythema sycosiforme 1 and ulerythema 
ophryogenes 2 are two other varieties of this form of disease. 
They bear a resemblance to the "folliculitis decalvans" 
of the French. They both affect hairy regions, the first 
having a predilection for the beard, and the second for the 
eyebrows. In their course they present symptoms somewhat 
like sycosis, but differ from that disease in causing perma- 
nent bald patches, and the destruction of the skin so as to 
form cicatrices. 

Ulerythema Acneiforme is the name given by Unna 3 to a 
purely local, probably parasitic disease of the skin which is 
limited to the neighborhood of individual hair follicles. It 
begins as an inflammatory erythema which, after persisting 
for some time, leads either to the formation of a well-marked 
cornification of the cuticle and comedones, or to cicatricial 
atrophy. 

It differs from acne by beginning on the middle of the 
cheek and margin of the auricle ; by extending to the hairy 
scalp ; by being primarily an inflammatory erythema ; by 
an absence of suppuration, and by atrophy occurring with- 
out suppuration. It differs from acne varioliformis by 
complete absence of necrosis, suppuration, and ulceration; 
by prominence of comedones; and by having no resemblance 
to variola in its scar. 

Uridrosis (IPr-iM-ro'-sr's). Synonyms : Sudor urinosis. 
By this is meant the excretion by the sweat pores of sweat 
loaded with the constituents of the urine, specially urea. 

1 Monatshefte f. prakt. Dermat., 1889, ix. No. 3. 

2 Ibid., No. 5. 

3 Internat. Atlas of Kare Skin Diseases, No. 1. 



URTICARIA. 549 

The sweat then often has a urinary order, and deposits crys- 
tals of urates upon the skin. It is always a complication of 
some grave general disease. 

Urticaria (U 5 r-ti 2 ka'-ri 2 a 3 ). Synonyms : Cnidosis ; (Fr.) 
Urticaire ; (Ger.) Nesselsuch, Nesselauschlag, Porcellan- 
friesel ; (Eng.) Nettle-rash, Hives. 

An acute or chronic disease of the skin characterized by 
the appearance of wheals. This usually trivial affection, so 
common as to be a matter of every-day occurrence, at times 
may assume grave symptoms, or entirely nonplus us by its 
persistency. It may run an acute or chronic course. 

Symptoms. The vast majority of cases run an acute 
course. The characteristic feature of the disease is the 
appearance of wheals — that is, firm, flat, circumscribed ele- 
vations of the skin which are at first pink, and then white. 
They may remain pink. They may be round, oval, annu- 
lar, or elongated, and are always surrounded by a red areola. 
They vary in size, sometimes being no larger than the head 
of a pin, and sometimes of the diameter of an inch. They 
show no tendency to group, but are irregularly disseminated 
over the whole body. Though they are not symmetrical in 
distribution, both sides of the body are affected at the same 
time, and they show some preference for the extensor sur- 
faces of the arms and legs. They itch, burn, and tingle, 
and are always scratched. They are ephemeral, each lesion 
lasting but a short time — from a few minutes to a day. Ex- 
ceptionally some wheals will last several days. New lesions 
crop out as old lesions fade, and thus the eruption is con- 
tinued. The mucous membranes are often affected at the 
same time with the skin ; and if the pharynx is attacked 
there may be suffocative symptoms. The duration of the 
disease as commonly met with is but a few days, and not 
infrequently the wheals may be entirely absent during the 
day, to break out again at night. Very often when the pa- 
tient is seen by the physician, he can find nothing but 
scratched papules. But the patient will tell him that when 
he is undressing, or is warm in bed, the itching becomes 
unbearable, and lumps looking like mosquito-bites break 

24* 



550 DISEASES OF THE SKLN. 

out upon him. The skin of a patient with urticaria is very 
irritable, so that a sharp tap upon it will produce a wheal. 

The outbreak of the disease may be sudden without con- 
stitutional disturbance, or there may be some burning and 
tingling of the skin before its appearance. Or there may 
be some febrile movement, and some evident disturbance 
of the digestion such as vomiting or dyspeptic symptoms. 
When the disease is cured the lesions disappear without 
desquamation, and leave no trace of themselves. Such is 
the acute form. 

Chronic urticaria differs from the acute form mainly in 
its duration. Instead of recovery taking place in a few days 
or weeks, its course is one of months or years. Sometimes 
the outbreaks of the eruption show marked periodicity, 
coming out at stated intervals after pauses of complete 
immunity. The eruption is generally not so extensive in 
the chronic as in the acute form. If the itching has been 
very severe and the scratching proportionally excessive, the 
skin may become pigmented, as in other chronic pruriginous 
diseases. 

The wheals assume different appearances in different cases, 
and different adjectives are used to express the varying pic- 
tures. It is not necessary to burden the mind with these, 
though they are convenient for descriptive purposes. Thus 
we have urticaria tuberosa seu gigans, where the lesions are 
unusually large ; urticaria bullosa, where the wheals are 
surmounted by bullse ; urticaria hcemorrhagica, where hem- 
orrhage into the wheals occurs ; urticaria oedematosa, prob- 
ably the same as acute circumscribed oedema, or acute angeio- 
neurotic oedema, where the wheal occurs in locations in which 
the subcutaneous tissues are lax, as about the eye, nearly 
closing it, or on the tongue, causing it to swell enormously 
and threaten suffocation; urticaria papulosa, or lichen urti- 
catus, where the wheals are small, a form common about the 
buttocks of children. 

Urticaria factitia is the name used to express the fact 
that, on account of the irritability of the skin, a wheal may 
readily be excited by local irritation. Urticaria perstans 



URTICARIA. 551 

simply refers to the persistent character of the single lesion. 
TJrticaria maculosa is the name proposed by Fournier for 
that form in which the wheal remains red. 

Etiology. The causes of the disease are more numerous 
than the forms it may assume. Most of the acute and many 
of the chronic cases are dependent upon irritating ingesta, 
such as shell-fish, strawberries, cheese, pickles, mushrooms, 
pork, sausages, even mutton in some, and almost anything 
in other people, it being largely a matter of idiosyncrasy ; 
medicinal substances, such as quinine, cubebs, copaiba, sali- 
cylic acid, opium, and other drugs. The rupture of hydatid 
cysts has been followed by urticaria. Dyspepsia in its 
various forms, and constipation, are common factors, especi- 
ally in chronic urticaria, as are intestinal worms in children. 
So also at times may be disorders of the liver, uterus, and 
ovaries. Some very severe cases occur during pregnancy. 
Gout, rheumatism, malaria, and functional or organic dis- 
eases of the nervous system will be found at the bottom of 
many cases of chronic urticaria. 

ISot only do we have internal causes producing the dis- 
ease, but also external causes, such as contact with the jelly- 
fish ; crawling of caterpillars ; the action of cold, or sudden 
changes of temperature ; the galvanic current ; and bites of 
insects. Urticaria is a common accompaniment of scabies 
and pedicululosis. 

Pathology. Urticaria is due to a vasomotor disturb- 
ance. At first there occurs a spasmodic contraction of the 
vessels of a circumscribed area of the skin, which is followed 
by paralytic dilatation of the vessels and retardation of the 
circulation. Serous exudation ensues, forming the wheal, 
which at first is pink, and then, becomes white, on account 
of the pressure of the fluid forcing out the blood from the 
central parts of the wheal. When the paresis ceases, the 
serous exudation is absorbed and the part returns to its 
normal condition. 

Diagnosis. The occurrence of wheals is pathognomonic 
of urticaria, as they occur in no other disease. When they 
are present, there is no difficulty in diagnosis. When they 
are not present and we find only scratch-marks we have to 



552 DISEASES OF THE SKIN. 

decide whether we have to do with urticaria or eczema, 
scabies, pediculosis, or dermatitis herpetiformis. Eczema dif- 
fers from urticaria in the tendency its lesions have of running 
together and forming patches. It never could be so generally 
distributed without presenting some characteristic patches. 
Scabies shows scratch-marks on the hands and feet, between 
the fingers and toes, in the axillse, about the umbilicus, and 
on the breasts of women and the penis of the male. The 
cuniculi may be found in most cases. Pediculosis shows 
long parallel scratch-marks over the back, between the 
shoulders, along the outside and inside of the limbs where 
the seams of the clothing come, and about the waist. Der- 
matitis herpetiformis presents grouped lesions, which usually 
are vesicles, but may be papules. Erythema of papular or 
tubercular variety may resemble urticaria, but it is a mark- 
edly symmetrical disease, and burns rather than itches. 

Treatment. In acute urticaria the administration of a 
prompt cathartic or saline laxative will usually cure the dis- 
ease if due to some irritating ingesta. Emetics might be 
useful, if we see the case before stomachic digestion is ended, 
but in most cases we are not called in until too late for them 
to be of service. Saline laxatives, mineral acids, rhubarb 
and soda, salol, resorcin, or other intestinal disinfectants are 
of service in the more chronic cases. Of course, if the erup- 
tion is due to the ingestion of drugs, they must be stopped. 
In chronic cases, besides medicinal treatment we must regu- 
late the diet, studying each case for itself. It is often well 
to put the patient on a strictly milk diet for a few days, and 
then add other articles with care. Alcoholics in all forms, 
and especially beer or other malt liquors, should be pro- 
hibited. If the gouty or rheumatic diathesis is at the foun- 
dation of the trouble, it must be combated. If the out- 
break shows marked periodicity, sulphate of quinine may do 
good. Salicylate of soda sometimes does good service even 
when there is no evident rheumatic tendency. In fact, we 
must endeavor in every way to get our patient into a normal 
state of health. The most difficult class of cases are those 
in which a neurosis alone seems to be the cause. Then bella- 
donna, atropia, arsenic, the bromides, antipyrine, phenace- 



URTICARIA. 553 

tin, and galvanism may be tried. Pilocarpine, wine of 
antimony, colchicum, ergot are also commended. In very 
obstinate cases the patient should be sent away from home 
and relieved from all business cares. 

Local treatment is of great service in allaying the itching, 
but it will not cure the disease. The parts may be sponged 
with alkaline lotions, such as a teaspoonful of baking-soda 
to a hand-basinful of water. Sometimes more relief is ob- 
tained by an acid solution, such as vinegar, pure or with 
water. Carbolic acid in vaseline, or alcohol and water, is 
sometimes very efficacious. In vaseline, 10 per cent, strength 
is sufficient ; in lotion-form we may use, to the adult skin, 
one to two drachms to the ounce, directing the patient to 
dab and not rub it on the skin. Hardaway prefers using 
the acid in a spray, two to four drachms to the pint, with 
one ounce of glycerin. To each atomizerful ten drops of oil 
of peppermint may be added to increase its antipruritic 
qualities. Menthol, 1 to 10 per cent, in alcohol or almond 
oil, is said to be efficacious. Crocker speaks highly of liquor 
carb. detergens, 5j to §iv ; terebene, 5iv to §iv ; and equal 
parts of sanitas and water. Salicylic acid, twenty grains to 
the ounce of castor oil, is good, but disagreeable. Camphor 
and chloral hydrate, each from half to one drachm, rubbed 
together and added to one ounce of starch or ungt. simplex, 
is another good antipruritic. Chloroform dabbed or sprayed 
on renders prompt relief. Baths are sometimes of use. 
Having the patient take a warm bath containing either two 
to six pounds of bran, or a quarter to half a pound of bi- 
carbonate of soda, or an ounce of nitro-muriatic acid, just 
before going to bed ; then drying the skin by wrapping 
in a warm sheet and patting the skin dry ; then smearing 
the skin with a film of vaseline and dredging over this corn- 
starch powder, will often give him a good night's rest. 

Prognosis. The vast majority of cases of urticaria re- 
cover in a few hours or days. The chronic cases often are 
most obstinate, but unless some severe nerve lesion is at the 
bottom of the case, they can be cured by patient and perse- 
vering effort. 

Urticaria Pigmentosa. Synonym : Xanthelasmoidea. 



554 DISEASES OF THE SKIN. 

Symptoms. This is not an ordinary urticaria, that, on 
account of its chronic course and the scratching to which it 
has been subjected, leaves more or less pigmentation of the 
skin. Such a condition of things is not infrequently seen. 
Urticaria pigmentosa begins within the first six months of 
life by an eruption of wheals or tubercles, which at first are 
about the size of a split-pea, and of a brownish or yellowish- 
red color, with a pink areola. Later, they may increase in 
size, or several may coalesce to form, a large one, and assume 
a yellow or buff color. These wheals appear in crops, and 
run a very chronic course, each one persisting for weeks or 
months. They then shrink, become softened, and disappear, 
leaving brownish pigmentation. As the course is chronic, we 
will find on the patient wheals or tubercles of red or yellow 
color, of various sizes, some hard and tense, some soft and 
wrinkled, and brown stains of the skin. Ordinary urtica- 
rial evanescent wheals will sometimes be found, and rubbing 
of the apparently stationary tubercles will cause some of 
them to enlarge. The wheals are most often located on the 
trunk and neck ; then on the limbs, face, and head ; but 
they may appear on any part of the body surface as well 
as on the mucous membranes of the mouth and pharynx. 
Itching may or may not be present. After a number of 
years the wheals will no longer come out, and recovery is 
generally complete at about the age of puberty, though the 
disease may last much longer than that. Morrow 1 has re- 
ported one case of over twenty years' duration. The major- 
ity of the cases, according to Crocker, occur in boys. We 
know no cause for the disease, and thus far treatment has 
been in vain. 

Vaccinal Eruptions. The eruptions that accompany or 
follow vaccination may be local, starting from the point of 
inoculation ; or general, and due to the absorption of the 
virus, which in some subjects acts as do medicinal sub- 
stances in other people. The majority of them are due not 
to any bad quality of the virus, but either to some accidental 
infection, or to idiosyncrasy. Sometimes an ulcer will form 

1 Journ. Cutan. and Gen.-Urin. Pis., 1895, xiii. 445. 



VARIOLA. 555 

at the site of the vaccination ; or starting from this pointwe 
may have a dermatitis, cellulitis, lymphangitis, erysipelas, 
abscesses, or furuncles. At times exuberant granulations, 
or what is called an infective granuloma, may develop upon 
the seat of the vaccination. An outbreak of impetigo con- 
tagiosa may originate from inoculation, the pus of the sore 
becoming transferred to other parts by the finger-nails ; or 
an eczema or psoriasis may be set up by the irritation of 
the sore, just as they may follow other affections of the 
skin. 

General eruptions usually appear, according to Harda- 
way, after the ninth or tenth day of vaccinia, and assume 
an erythematous, papular, or papulo-vesicular character. 
The roseola vaccina of Hebra is an erythematous eruption 
of macular character, commencing usually upon the arms, 
and sometimes spreading over the whole body. It is accom- 
panied in some cases with slight rise of temperature for a 
few hours. It disappears and leaves no trace. 

We may also encounter erythema multiforme and urticaria 
complicating vaccination. It is possible that a bullous erup- 
tion may occur, but this is very rare. Syphilis also may be 
inoculated in arm-to-arm vaccination. Grangrene may occur 
in the sore and other accidents. All of these eruptions are 
rare. 

Varicella (Va 2 r-i 2 -se 2 l / la 3 ), or Chicken-pox, is an eruptive 
fever of mild grade, which is characterized by an outbreak 
of a greater or less number of clear vesicles, of pin-head- 
to pea-size, and varying shape, that come out in crops. A 
long vesicle is very characteristic of this eruption. There 
is usually only slight constitutional disturbance. The 
mucous membranes may be involved. 

Varicella Gangrenosa. See Dermatitis gangrenosa in- 
fantum. 

Variola (Va 2 r-iVl-a 3 ), or Smallpox, is an acute contagious 
eruptive fever, characterized by very severe prodromal symp- 
toms, such as headache and intense pain in the back and 
legs, and the appearance, usually on the third day, of an 



556 DISEASES OF THE SKIN. 

eruption of minute red spots that soon change into small, 
round, hard, shotty papules. The eruption is first seen on 
the face about the mouth and on the neck and wrists. In 
about twenty-four hours after its first appearance vesicles 
form upon the papules, and attain their full development by 
about the fifth day. They then are umbilicated, are located 
upon a hard base, and have a well-marked areola. Now 
they change into pustules, and a well-marked secondary fever 
attends the change. After about four or five days the pus- 
tules dry up into crusts, and afterward these fall, leaving 
pitted cicatrices in many places. The mucous membranes 
may be involved. In varioloid, modified smallpox, the 
constitutional symptoms as well as the eruption are of much 
milder grade. 

Diagnosis. Variola bears a resemblance to the pustular 
syphilide ; for the differential diagnosis, see the " pustular 
syphilide." Acne and pustular eczema both have lesions 
resembling those of variola, but are limited to certain re- 
gions, and are not general eruptions. Varicella and papu- 
lar erythema have been mistaken for variola. In its earlier 
stages the diagnosis of variola is very difficult. In pro- 
nounced cases, on the other hand, the diagnosis is easy. 

Varus. See Acne. 

Vegetation dermique. See Verruca. 

Vegetations. See Verruca. 

Venereal Wart. See Verruca. 

Verbrennung. See Dermatitis ambustionis. 

Verruca (Ve 2 r-ru 2/ ka 3 ). Synonyms ; (Fr.) Verrue ; (Ger.) 
Warze; Warts. 

These exceedingly common papillary outgrowths assume 
various appearances, to which descriptive names have been 
given. Thus we have verruca vulgaris, or the wart so often 
seen on the hands of children and young people. They 
vary in size from that of a hemp-seed to that of a split-pea, 
or larger where two or more become aggregated. They are 
sessile, hard, conical, with flattened tops. They may be 



VERRUCA. 557 

smooth, or uneven, showing their papillary formation. They 
may be of the color of the skin, or some shade of yellow, 
brown, black, or green. There may be a number of them, 
and they may be isolated or aggregated. They may occur 
elsewhere than on the hands. Verruca digitata is applied 
to a wart in which the papillae are separated distinctly from 
each other. They occur in groups, and are often seen on 
the scalp. Verruca filiformis is a wart in which the papillae 
are not only distinct but fine, almost thread-like. Each 
papillary outgrowth stands by itself. They are soft to the 
touch, and occur on the face, eyelids, and neck. Verruca 
plana are flat warts, but slightly elevated, and varying in 
size from a pin's head to a half-inch in diameter. They 
sometimes occur in large numbers. In young people they 
occur upon the face and backs of the hands, and may or may 
not be pigmented. In old people they occur on the trunk 
and arms and are pigmented. In them they are called 
verruca senilis, or seborrheal warts. Verruca acuminata, 
also called condyloma acuminata, vegetations dermiques, 
spitzen warzen, and venereal or moist warts, are met with 
in the anal and genital regions of both sexes, as also in the 
axillae, under the hanging breasts, in the umbilicus, and 
between the toes. They are vascular, sessile or peduncu- 
lated, and composed of a great number of closely aggregated 
projections of various shapes. On exposed situations they 
are dry and of the color of the skin ; while in locations that 
are moist — that is, between the skin-folds — they are covered 
with a whitish puriform secretion, and, unless kept very 
clean, they emit an offensive odor. They sometimes attain 
to an immense size. 

Etiology. We do not know the cause of warts. They 
are regarded by some as contagious, and parasites have been 
isolated and declared to be the morbific agents. They occur 
more frequently in the young than in the old, and may be 
congenita]. Verruca acuminata are traceable to irritating 
discharges, but not by any means always to a gonorrhoea. 
They are undoubtedly contagious. 

Treatment. The treatment of most all warts is prompt 
and efficient by means of the curette, scraping them off 



558 DISEASES OF THE SKIN. 

while the skin is slightly stretched. If there is any doubt 
about their returning, their bases may be touched with iodine 
or nitric acid. Generally simple scraping is sufficient. 
Electrolysis may be used. The digitate and filiform warts may 
be snipped oif with the scissors. If operative interference is 
refused, the warts may be removed by painting with tincture 
of iodine ; or a saturated solution of salicylic acid ; or a 20 per 
cent, solution of resorcin ; tincture of thuya ; or nitric or 
glacial acetic acid. In the country children's warts are 
removable in some cases by the application of the juice of the 
common milk-weed. Acuminate warts may be removed by 
keeping them clean and dry, and painting them with liq. 
plumbi subacetatis, or a solution of the perchloride or per- 
sulphate of iron ; or dusting them with salicylic acid and 
starch, or boric acid. Chromic acid is a powerful caustic. 
Caustic potash is not a safe one to use, unless care is had to 
limit its action by a ring of wax about the wart. The gal- 
vano-cautery may also be employed. 

It is said that warts may be removed by internal treatment. 
Sulphate of magnesia, two or three grains to a child and 
half a drachm to an adult, three times a day, is one remedy. 
Besnier has tried this method in a number of cases with ab- 
solute unsuccess. Tincture of thuya occidentalis, two or 
three times a day, is said to be efficacious. Crocker thinks 
he has seen cures effected with full doses of nitro-muriatic 
acid, while others advocate arsenic. 

Warts very often disappear of themselves, and no one has 
ever seen them fall. 

Verruca Necrogenica. See Tuberculosis verrucosa cutis. 

Verrue. See Verruca. 

Verrue Telangiectasique. See Angiokeratoma. 

Verrugas, Endemic. See Yaws. 

Vibices. See Purpura. 

Vitiligo. See Leucoderma. 

Vitiligo Capitis. See Alopecia Areata. 

Vitiligoidea. See Leucoderma. 



XANTHOMA. . 559 

Wart. See Verruca. 
Warze. See Verruca, 
Warzenkrebs. See Carcinoma. 
Warzenmal. See Nsevus verrucosus. 

Washleather Skin is that condition of the skin in which 
certain metals, specially silver, mark it with a black line. It 
occurs, as a rule, in patients suffering from diseases which 
directly or indirectly affect either the trophic or the sensory 
nerves, such as renal disease, phthisis, erysipelas, and 
hemiplegia. It sometimes precedes the occurrence of bed- 
sores. 

Weichselzopf. See Plica. 

Wen. See Sebaceous cyst. 

Whelk. See Acne. 

Xanthelasma. See Xanthoma. 

Xanthoma (Za 2 nth-om / -a 3 ). Synonyms : Xanthelasma ; 
Vitiligoidea ; Molluscum cholesterique ; Fibroma lipoma- 
todes. 

A peculiar disease of the skin characterized by the ap- 
pearance of discrete patches, or tubercles, of chamois or 
lemon-yellow color. 

Symptoms. Xanthoma may assume one of two forms : 
Xanthoma 'planum, or Xanthoma tuberosum or tubercu- 
latum. In the former we meet with flat, chamois-leather, 
or lemon-yellow plates that are either slightly raised above 
the level of the skin, or not at all raised. They vary in 
size from an eighth of an inch to an inch in their long 
diameter, feel soft and smooth to the touch, and when 
pinched between the fingers no infiltration of the skin is 
perceptible. They are irregular in shape, tending to form 
elongated figures. When in patches they feel almost vel- 
vety, and when examined with a lens they are seen to con- 
sist of an aggregation of small granules, many of which 
have a central pinkish punctum. 

Xanthoma tuberosum exhibits lesions of the same color 



560 DISEASES OF THE SKIN. 

as does the plain variety, or they may be of reddish-yellow, 
but they are raised above the skin and may attain to a large 
size. They are soft, smooth, round, or oval, with telan- 
giectases over them when small. When large, they are firmer 
and more irregular in shape, being made up by aggregation 
of a number of smaller tubercles. Xanthoma multiplex is 
the name applied to cases in which both varieties are present. 
In all forms, unless there is jaundice, the skin between and 
about the lesions is normal in color. Most cases give rise 
to no subjective symptoms, but there may be some itching 
or burning If the disease occur upon the palms or knees, 
it may cause discomfort or even pain on kneeling or hand- 
ling objects. 

The favorite seat of xanthoma planum is in the upper 
eyelid, where they are not infrequently seen. There they 
commence at the inner canthus, most often of the left eye, 
and spread in a semicircle about the eye, while shortly after- 
ward a similar growth begins on the right upper eyelid. 
Next in point of frequency to the eyelids, they occur upon 
the flexures and mucous membranes. Xanthoma tubero- 
sum is most frequently seen upon the knees, elbows, knuc- 
kles and other points of pressure, the trunk being not so 
much affected. Symmetry is generally observed. Xan- 
thoma multiplex is often very widely distributed. Some- 
times the lesions run in streaks, or, as in Hardaway's case, 1 
are arranged like a zoster. The following case reported by 
me 2 is one of the most extensive on record : 3 

Michael M , aged five years, was admitted to my service 
at the Randall's Island Hospital in May, 1890. From 
the child's sister I have been able to gather the following 
imperfect history : The eruption appeared when the child 
was three months old, without any antecedent disease, 
and came out all over the body at the same time. It is 
thought that no new lesions have appeared since then ; 
that there has been change in the size of the lesions, and 

1 St. Louis Courier of Med , October, 1884 

2 Journ. Cutan. aud Gen.-urin. Dis. , 1890, viii. 241. 

3 See frontispiece for illustration. 



XANTHOMA. 561 

that some of them have disappeared. The boy is said to 
have always been well, to have played about like other boys, 
and never to have been jaundiced. 

Examination of the boy reveals a very extraordinary con- 
dition of affairs : the whole body of the boy is occupied by 
a disseminated efflorescence, no part being spared except the 
hands, feet, and scalp. The lesions are about the size of a 
split-pea, or a little smaller, are soft to the touch, and have 
a central depression. Upon the face, trunk, shoulders, and 
lower part of the legs they are discrete, and scattered about 
without any particular arrangement. Upon the extremities 
the lesions are crowded into patches of various sizes and 
shapes, with normal skin between them. Even in the patches 
the lesions are distinct. They touch each other but do not 
coalesce. The distribution of the lesions and of the patches 
is quite symmetrical. The color varies from a lemon-yellow 
in the discrete lesions on the shoulders to an orange-yellow 
in the patches. About the joints the color is reddish-brown. 

In the right eyelid are well-marked, typical xanthomatous 
patches of chamois-leather color. The lower lid is occupied 
by one continuous patch, running from the inner to the outer 
canthus. On the upper lid there is a small tumor. The 
left lid is but very slightly affected. Upon the back of the 
neck and the upper part of the back are a number of light- 
brown pigmentary spots, which the sister says are the re- 
mains of some lesions that have disappeared. Scattered 
about the trunk are a number of depressed scars, apparently 
the remains of a recent varicella. 

The boy is very thin, of blonde type, and the skin is pale. 
Apart from this there is nothing abnormal. His appetite 
is good, his digestion is in fine condition, and his urine con- 
tains neither albumin nor sugar. Upon the left buttock 
there is one vascular nsevus. 

The skin in Xanthoma is not alone aifected. Xanthoma- 
tous bodies are found in the liver, mucous membranes, and 
tendons. The disease is progressive for a time, and then 
may remain stationary for years, or may undergo sponta- 
neous resolution. 



562 DISEASES OF THE SKIN 

Etiology. Xanthoma occurs much more frequently in 
adults than in children, and that form that occurs in the 
eyelids is much more common in women than in men. 
Several cases may be seen in the same family, and the dis- 
ease is sometimes hereditary. But we really do not know 
as yet what is the cause of the disease, though various theo- 
ries have been advanced. Hepatic diseases ; diabetes ; dia- 
thetic conditions of various kinds ; migraine ; embryonic 
cells left in the skin ; each have been found in connection 
with one or many cases. Hardaway may not be wrong in 
his idea that it is a diathetic disease, and that when it occurs 
with jaundice it is because the same tubercles have been 
deposited in the liver as in the skin, and the jaundice is 
secondary to them. 

Pathology. It is a connective-tissue new growth con- 
taining an abundance of fat. Between the connective-tis- 
sue bundles the so-called u xanthoma cells " are found. The 
color of the lesions is due to fat-globules. (Heitzmann.) 

Diagnosis. The diagnosis of this unique disease is made 
by the occurrence of chamois-leather-colored soft plates or 
tubercles, such as occur in no other disease. Milium may 
bear some slight resemblance to xanthoma, but it is hard 
and firm, not soft and velvety, and white, not yellow. It is 
easily squeezed out after a prick through the skin over 
it, an impossibility in xanthoma. 

Treatment. In the way of treatment we have no sure 
resource save the knife and electrolysis. The latter is the 
more preferable of the two. In so general a case as mine, 
neither plan w T ould be applicable. Besnier 1 reports good re- 
sults from the administration of phosphorus in cod-liver 
oil, giving one milligramme per day, and increasing the dose 
each day by a quarter of a milligramme until three milli- 
grammes are taken. After fifteen days this is stopped and 
turpentine is given. Stern 2 tried this plan without success, 
but succeeded in removing patches of the disease from the 
eyelids by the use of a ten per cent, solution of corrosive 

1 Journ de Med. et de Chir., April, 1886. 

2 Berlin, klin Woch., 1888, xxv. 393. 



TAWS. 563 

sublimate in collodion. Shepherd, of Montreal, saw one 
case recover after an operation for biliary calculi. 

Xanthoma Diabeticorum. Besides the xanthoma just 
described there is another form which is regarded by many 
as a distinct affection, and called Xanthoma diabeticorum. 

Symptoms. It is an exceedingly rare disease, which dif- 
fers from ordinary xanthoma in its more sudden develop- 
ment ; in disappearing sooner or later, perhaps to recur; by 
the hardness of its lesions, which are never macular; by 
the frequent absence of a yellow color ; by the presence of 
a certain amount of inflammation; by absence of jaundice, 
and presence of diabetes mellitus ; by its more pruriginous 
character ; by avoiding the eyelids ; and by having its lesions 
about the mouths of the hair follicles. In fact it resembles 
ordinary xanthoma mostly in its location upon the elbows, 
knees, and other points of pressure, and in the general con- 
figuration of the lesions. The treatment should be directed 
to the diabetes, which is at the foundation of the disease, and 
to the allaying of the itching. 

Xeroderma. See Ichthyosis. 

Xeroderma Pigmentosum. See Atrophoderma pigmen- 
tosum. 

Yaws 1 (Ya 4 z). Synonyms : Framboesia ; Pian ; Parangi ; 
Verruga. 

This is a disease that occurs only in tropical countries. 
The stage of incubation lasts two to eight weeks and is with- 
out special symptoms. The stage of invasion, with more or 
less well-marked fever, which abates before the eruption 
appears, lasts one or two weeks. The eruption is preceded 
by enlargement and tenderness of the lymphatic glands, and 
consists of pin -head to lentil-sized, slightly elevated papules 
on a broad base. The papules enlarge, the epidermis splits 
and curls off from their centers, and exposes a yellowish 
point which develops into a flat, moist, red, or pink tumor, 
looking not unlike a raspberry. These tumors range in 

1 This account is condensed from Crocker. 



564 DISEASES OF THE SKW. 

size from a split-pea to a nut, are round or oval, discrete, 
or coalesced into large irregular masses. The surface of 
the tumor is covered with a thin, yellowish, foul-smelling 
discharge, that dries into scabs, which may ultimately form 
rupia-like crusts. In the mouth and in moist situations no 
crusts form, and the tumors will resemble mucous patches. 
They reach their full development in from two to four weeks, 
remain stationary for months, and then dry up and fall off, 
leaving a spot on the skin that eventually disappears. They 
may break down and ulcerate, involving both the adjacent 
soft parts and the bones. The tumors are not tender. The 
disease tends to recovery, but is subject to relapses. It is 
contagious, and one attack is protective to a certain extent. 
Death occurs in bad cases. 

Treatment. The treatment is hygienic and by tonics. 
Locally, disinfectant applications should be used. 

Zaraath. See Lepra. 

Zona. See Zoster. 

Zoster (Zo 2 st'u 5 r). Synonyms: Zona; Herpes zoster; 
Ignis sacer; (Ger.) Feuergiirtel, Giirtelkrankheit ; Shingles. 

An acute disease of the skin characterized by a unilateral 
eruption of groups of vesicles upon reddened bases scattered 
along the course of certain nerves. 

Symptoms. Zoster, like psoriasis, presents such marked 
lesions that once seen it is readily recognized when seen 
again. It occurs in the form of groups of vesicles seated 
upon red bases, and arranged along the course of nerves 
upon which there are ganglia. (Fig. 69.) The vesicles are 
at first filled with serum that afterward may become cloudy. 
They do not tend to break down of themselves, but are fre- 
quently ruptured by accident. The size of the groups 
varies greatly. There may be but a few vesicles or a large 
number of them closely crowded together. Sometimes a 
group is no larger than a three-cent piece, and sometimes it 
is several inches in its longest diameter. Sometimes the 
vesicles may run together and form blebs. The shape of 
the groups is always irregular. There may be but two or 
three groups or a score of them. In nearly all cases the 



ZOSTER. 



565 



disease is unilateral, though it is not uncommon for one or 
two groups to be found close to the middle line, on the side 
opposite to the site of the disease, and cases of double zoster 
occur, though very rarely. All the groups do not come out 
at once, but, as it were, by a series of outbreaks, the earliest 
ones to appear usually being those nearest the point of exit 
of the nerve. The eruption is usually at its height in a 
week, the vesicles drying up, forming a crust and falling off, 
leaving a red mark that soon fades. The whole duration of 
the disease is from ten days to three or four weeks. 

Fig. 69. 




Zoster of arm. 



In many, if not most cases, the patient experiences neu- 
ralgic pain in the nerve along whose course the eruption is 
about to appear. This is sometimes wanting, and generally 
lessens or disappears when the eruption appears. Some- 
times the pain is severe during the duration of the eruption, 
and after it is gone. Tender points may often be found over 
the points of exit of the nerves, just as are found in neural- 
gia. In some patients there will be fever before the out- 
break of the vesicles or the successive appearance of new 
groups. The vesicular stage is preceded by an erythemato- 
papular stage. Very rarely some of the groups may abort 
at this stage. Exceptionally, zoster may occur on both sides 
of the body. In nearly all cases the disease does not recur. 

25 



566 DISEASES OF THE SKIN. 

Exceptionally, a patient may have several attacks of the 
disease. 

Most cases of zoster occur upon the trunk, and, it is said, 
especially on its right side. It also occurs upon the face, 
on branches of the fifth nerve, when it may involve the eye, 
and produce blindness by destructive ulceration. The neck 
may be affected, and with it the arm. The leg, too, may 
suffer. Generally the eruption does not reach further down 
than the elbow and knee, though it may occupy the forearm 
and hand, leg and foot. In rare instances the tongue and 
pharynx may be affected. Various names are used to 
designate the location of the eruption, such as zoster fron- 
talis, ophthalmicus, cervicalis, intercostalis, genito-cruralis, 
and the like. 

In rare cases hemorrhage may occur into the vesicles, or 
they may be purulent from the start, or they may ulcerate, 
or become gangrenous. The neuralgia may continue in old 
or debilitated subjects in so severe a manner as to threaten 
the exhaustion of the patient from pain and loss of sleep. 
Or pruritus, hyperesthesia, or anaesthesia may be left for 
some time after the disappearance of the eruption. Or 
paralysis of motion may follow the attack, as well as atrophy 
of muscles. Scars will follow the disease if ulceration has 
occurred. 

Etiology. Zoster occurs more often in children than 
adults. Sex seems to have little influence. It follows upon 
injuries to nerves in some cases, and has been associated 
with caries of the ribs. It has been known to occur while 
the patient was taking arsenic. It occurs frequently in the 
damp cold weather of the spring and autumn, so much so as 
to give rise to epidemics. Indeed, some regard the disease 
as infectious on account of the epidemic character it some- 
times has. Some cases seem to arise from peripheral irri- 
tation of cutaneous nerves. A descending peripheral neu- 
ritis of the spinal ganglion is regarded by Crocker as the 
condition most frequently associated with the disease. In a 
great number of cases disease of the ganglia upon the poste- 
rior roots of the spinal nerves has been found post mortem. 
When the fifth nerve is affected it is the Gasserian ganglion 



ZOSTER. 567 

that is diseased. Zoster may arise from injury, as a wound 
of a nerve-trunk, and then we may have an ascending zoster, 
the first group being nearest the point of injury. 

Diagnosis. Zoster in most cases is readily recogniza- 
ble. It differs from eczema in having larger vesicles that 
do not tend to rupture ; in its patchy character, the patches 
being located along certain nerve-trunks ; in the neuralgia 
that accompanies it ; and in the definite course that it runs. 
Herpes facialis or progenitalis sometimes resembles zoster 
quite closely, but in them there will often be a history of 
previous attacks; they will not occur so markedly as groups 
of vesicles upon one side alone ; and they will not be pre- 
ceded by the same amount of neuralgia. By some authori- 
ties herpes and zoster are considered to be the same dis- 
ease. 

Treatment. The most important part of the treatment 
of zoster is to prevent the breaking of the vesicles, and the 
possible ulceration that would follow and leave scars. To 
this end we should avoid ointments and use dusting-powders, 
such as oxide of zinc, or bismuth, or starch, or, what is 
better, we should paint the vesicles with flexible collodion 
with or without morphine, which sometimes seems to abort the 
formation of vesicles. It is also advisable to cover the 
eruption with a soft linen bandage to prevent rubbing. If 
the vesicles have become broken and ulceration has ensued, 
then we have to treat the ulcers on surgical principles. 

To relieve the pain of zoster the galvanic current gives 
the best results, one sponge electrode being placed over 
the spine, and a roller electrode attached to the other 
pole and passed around the groups for ten or fifteen minutes 
once or twice a day. A current-strength of two or three 
milliamperes may be used, and, if it can be done, the last 
application should be made just before going to bed. Other 
means are hypodermatics of morphine ; blistering over the 
root of the nerve; and the use of the menthol cone or oil of 
peppermint. Phosphide of zinc, one-third of a grain every 
three hours, is thought by some to relieve the pain and limit 
the eruption. For the persistent neuralgia that at times 
follows these cases, arsenic, or strychnine, iron, quinine, cod- 



568 DISEASES OF THE SKIM 

liver oil, and a good nutritious diet are necessary- Opium 
may have to be given to allay pain and procure sleep. 

Prognosis. Most cases of zoster run a favorable course 
and get well of themselves. It is only in old or debilitated 
people that we need fear any serious results. There is 
always the possibility of the occurrence of ulceration and 
gangrene, though it is not to be expected in the vast majority 
of cases. The popular opinion that if zoster occurs on both 
sides at once and forms a girdle the patient will die. is not 
borne out by the facts. 



APPENDIX. 



The following formulae are given as guides in the preparation of 
prescriptions for the treatment of skin diseases. Many, if not all of 
them, have been well tried and their value proved : 



A. BATHS. 



Simple Water Baths 



Cold 


. 40° - 65° F. 


Cool 


. 65°-75°F 


Tepid 


. 85° - 95° F 


Warm ..... 


. 95°-100° F 


Hot 


. 100°-110° F 



Wet Pack. Wrap patient in wet sheet and roll up in a blanket. 
After twenty to thirty minutes remove the pack, rub dry, and anoint 
with oil or ointment. Useful to remove the scales in psoriasis and to 
diminish hyperemia. 

Medicated Baths. To an ordinary bath-tubful, say thirty gallons 
of water, add for 



Bran bath . 
Potato-starch bath 
Gelatin bath 
Lindseed " 
Marshmallow bath 
Size bath . 



2 to 6 lbs. bran. 
1 lb. starch. 

1 to 3 lbs. gelatin. 

1 lb. linseed. 

4 lbs marshmallow. 

2 to 4 " size. 



These baths are useful in erythematous, itchy, and scaly diseases. 



Bicarbonate of soda bath . 
Carbonate of potassium bath 
Borax bath 



To bath. 
2 to 10 ounces. 
2 to 6 " 
3 " 



These baths are useful in eczema, psoriasis, urticaria, prurigo, and 
pruritic diseases. 

To bath. 
Nitric acid bath . . . , .1 ounce. 

Muriatic acid bath . . . . . 1 " 
Or may use of each . . . . - i " 

Of use in chronic pruritic diseases. 



570 APPENDIX. 

Iodine Bath : 

To bath. 

Iodine . . . . . ^ to 1 drachm. 
Iodide of potassium vel ... J ounce. 

Liquor potass. . . . 1 to 2 ounces. 

Glycerin 2 " 

Useful in scrofulous and squamous diseases. 
Bromine Bath : 

To bath. 
Bromine ....... 20 drops. 

Iodide of potassium .... 2 ounces. 

Same indications as iodine bath. 

To bath. 
Potass, sulphuret • . . . 2 to 4 ounces. 

Used in scabies, chronic eczema, lichen, and psoriasis. 

Startin's Compound Sulphur Bath: 

To bath. 

Precipitated sulphur ... .2 ounces. 

Hyposulphite of soda ... 1 ounce. 

Water ....... 1 pint. 

Water ....... 1 pint. 

Same indications as the sulphuret of potassium bath. 

Mercurial Bath : 

To bath. 

Bichloride of mercury ... .3 drachms. 
Hydrochloric acid . . . . 1 drachm. 

Water . 1 pint. 

Used in pityriasis rubra and the syphilides. 



B. INTERNAL USE. 

1. Turpentine Emulsion : 

R. 01. terebinthinse, 
01. limonis, 
Mucilag. acaciae, 
Aquae, ifss; 16 M. 

Sig. A teaspoonful three times a day immediately after meals. 
One quart of barley water to be drank during twenty -four hours. 
(Crocker.) 

Used in psoriasis, eczema, and hyperemias. 



Tftx-xxx ; 


0.66-2 


1UiJ; 

% ss; 


16 
16 



APPENDIX. 



571 



2. Mixed Treatment : 

a. ]£. Hydrarg. bichlor., gr. j-iij ; 

Potass, iodid , 3 iv-viij 

Tinct cinchon. co., ^iijss ; 

Aquae, % ss ; 



:06-.2 



16-32) 

112; 

16 



M. 



Sig. One drachm in water t. i. d. one hour after meals. (Taylor.) 

b. R. Hydrarg. biniod., gr. ss-ij ; 03-13 

Ammon. iodid , 3 SS ; 2 

Potass, iodid., .^ij~,?j; 8-32; 

Syr. aurant cort., jfjss; 48 1 

Tinct. aurant. cort , 3 j ; 4i 

Aquae, ad ^iij. 100 

Sig. One-half ounce t. i. d after meals (Keyes ) 



M. 



c. rj • Hydrarg. bichlor. vel, \ 
Hydrarg. biniod , j 
Potass, iodid., 
Inf. gent. co. vel, ") 

Syr. sarsaparillae co , J ^ 

Sig. One drachm t. i. d. after meals 
These three are used in syphilis. 



g r - j-y ; 
3j-ij ; 

3iv, 



06-13 



4-8 
128 



M 



3. R. Gurjun oil, Jfj ; 
Liquor calcis, % iij ; 

Sig. One-half ounce twice a day. 


33|33 
100| 


Used in leprosy. 




4. R . Tinct. guaiaci, Hlxl ; 
Tinct. aconiti, Tilij ; 
Aq camphorae, % ss ; 


2 
16 


66 

13 



M. 



M. 

Used in chronic skin diseases, specially with rheumatic taint. (T. 

Fox.) 



R . Tinct. cannabis indicae, TTlx-xxx ; 0. 66-2 
Pulv. tragacanth co., gr.x; 



Q6 



Aquae, 
Used in pruritus and prurigo 

6. Startin's Mixture : 



32 



M. 



(Bulkley.; 



. Magnesii sulphat., 
Ferri sulphat., 
Ac. sulphur, dil , 




20-30 
3 
6 


Syr. pruni virgin., 
Aquae, 


|j; 

ad ^ iv ; 


24 
100 



M. 



SLg. One drachm t. i. d. after meals, through a tube. 



572 



APPENDIX. 



7. Astatic Pills: 



R. Ac. arsenici, 
Pulv. pip. nigrse, 
Gum Arabic, \ 



gr. lxvj. 
^ix. 

q. s. 



Aquae, ' / "** * »• m. 

Div. in pil. no. dccc. 

Sig One to three pills a day after meals and increase to tolerance. 

Used in psoriasis. 



R. Pil. hydrarg., ^ij; 

Ferri sulphat. exsic, 9j ; 

Ext. opii, gr. v ; 

Div. in. pil. no. xl. 
Sig. One t i. d. (Taylor.) 



33 M. 



Used in syphilis. Sulphate of quinine may be substituted for the 



iron. 



9. R . Hydrarg. chlor. mitis, gr. jss 

Ferri lactatis, gr. iij ; 

Sacch. alb., gr. xv; 

Ft. in pulv. no x. 

Sig. One to four daily. (Monti.) 

Used in infantile syphilis. 



M. 



C. EXTEKNAL USE. 



a. Caustics. 



1. Cosine's Paste 



R . Ac. arseniosi, 

Hydrarg. sulphuret. rub., 
Ungt. rosee vel, \ 



gr. x; 

3ss; 

^ss; 



Sacch. alb., 
To destroy epithelioma or other new growths. 



2 
16 



66 



M. 



2. Marsden's Paste : 

R . Pulv. ac. arseniosi, 
Pulv. gum acaciae 



!'} 



aa 3j; 



M. 



Mixed with water to form a paste just before using, and apply to not 
more than one square inch at a time. 
Same indications as last. 



APPENDIX. 573 



3. Bougard's Paste: 



R. Wheat flour, \ fi0 

Starch, ; aa b °P arts ' 

Arsenic, 1 part. 

Cinnabar, 1 __ K , 

o i • >■ aa 5 parts. 

Sal ammoniac, J r 

Corrosive sublimate, J part. 

Sol. chlor. of zinc @ 52°, 245 parts. M. 

Grind first six ingredients to a fine powder, then mix them in a 
mortar. Add solution of acid, slowly stirring. Keep in earthen jar. 

Sig. Apply accurately to part ; keep on for thirty hours ; follow with 
poultice. 

4. Depilatory Paste : 

R. Barium sulphid., gij; 8 

f^if di ' I aa 3i; j ; 12 m. 

Make into a paste with water and apply a thin coating for ten to 
fifteen minutes , then clean off and apply a bland ointment. 

5. Salicylic Acid (Crocker) : 

&. Glycerini, |j ; 32 

Ac. salicyl., q. s. ; M. 

Make in consistency of thick cream. To lessen painfulness of appli- 
cation may add 

Ifc. Ac. carbolici vel, 1 _ • ^i 

Creosote, / 3J ' | M. 

Used to destroy warts, lupus, and epidermic thickenings. 

6. Vienna Paste : 

K " S^' \ aa p. «. M. 

Jrotassae, J r 

Make into a paste with alcohol just before using. 
Used in lupus and scrofulides. 

7. Canquoiri's Paste : 

R.Zinci chlor j ftft . 4 j 

Ammon. chlor., J OJ ' j 

Pulv. amyli, g jss ; 6j 

Aquae, q. s. ; ' M. 

Make into a paste at time of using. 

Used to destroy lupus, epithelioma, and the like. 

25* 



574 



APPENDIX. 



8. Middlesex Hospital Paste : 

R . Zinci chlor. , ") 
Liq. opii sed ., J 
Amyli, 
Aquae, 

Same indication as last. 

9. R . Zinci nitrat., 

Bread mass, 

Mix before using. 



aa 



3j; 



6 
32 



1 part. 

2 parts. 



&. Lotions. 



1. Belladonna Lotion 



R. Tr. belladon., ") 
Glycerini, J 
Aquse, 

Sig. For erysipelas. (Piffard. 



1 part. 

8 parts. 



gr. vijss ; 
gss; 

3j; 



2. Bismuth Lotion : 

R . Bismuth, subnitrat , 
Zinci oxidi, 
Glycerini, 
Hydrarg. bichlor., 
Aquse rosae, 

For rosacea and hyperaemic conditions. 

3. Calamine Liniment : 

R. Pulv. calamine, J}ij 

Zinci oxidi, 3 ss ; 

Carron oil, ^j ; 

For erythema, eczema, and hyperaemic conditions. 

4. Calamine Lotion : 

R. Pulv. calamine, 
Zinci oxidi, 
Glycerini, 
Aq. rosae, 

For erythema and eczema. 

5. Carbolic Acid Lotion : 



2 
1 

32 



016 



3ss; 
TTUv 

3j; 



2i66 

2 

32 



2|66 

2 



1 
321 



R. Ac. carbol., 
Alcohol, \ 
Aquae, J 

Sig. For erysipelas. (White.) 



3j; 

aa Oss ; 



4, 
250 



M. 



M. 



M. 



M. 



M. 



M. 



M. 



APPENDIX. 



bib 



6. Corron Oil : 






R. Aq. calcis, "] 
01. olivae vel, [ 
01. lini, J 


Equal parts. 


For burns. 






7. Coster's Paint : 






R. Iodine, 

01. picis liquidae, 


3HJ ; 

3J; 


4-8 1 
30i 


8. Fox's C. C C. Mixture: 






R. Chrysarobin, ") 
01 cadini, J 
Ac. carbolici, 
Ac oleici, 

Sig. In psoriasis. 


aa 2 

1 

50 


parts. 

part. 

parts. 


9. LTardaway' s Lotion for Lichen 


Planus : 




R . Sapo olivae prep., 
01 rusci, \ 
Glycerini, | 
01. rosmarini, 
Alcoholis, ad 


3 vii J ; 


100 
25 

4 

200 


10. Kaposi's Tar Lotion : 






R. 01. rusci, 

Etheris sulphuris, \ 
Alcoholis, j 
Filter and add 

01. lavandulae, 

Used in psoriasis. 


50 
aa 75 

2 


parts. 

u 

a 


11. Kummerfeld's Lotion : 






R . Spts. camphorae, "I 
Spts lavandulae, J 
Sulph praecip.. 
Aq. cologniensis, 
Aq. destil., 


aa ^ss; 
gr. xv 

3j; 

31J; 


2 

1 

4 
60 


For cosmetique. 






12. Liquor Picis Alkalinus : 






R . Picis liquidae, 
Potass causticae, 
Aquae, 


fij; 

3"v; 


25 
12 5 
100 



M 



M. 



M. 



M. 



M. 



M. 



M. 

(Dissolve the potassa in the water and add slowly the tar in a mortar 
with friction.) 

In chronic eczema, or, diluted ten to twenty times, in acute eczema. 



576 



APPENDIX. 



13. Lotto Alba: 

R . Potass, sulphurat., \ 
Zinci sulphat., } 

Aquae rosae, 

In acne and rosacea. 



aa 3 j ; 



4 

128 



M. 



14. Lotio Ac. Boraeis : 

JR. Ac. boraeis, giv vel q. s. ; 16 

Etheris sulph. methyl., jf v ; 160 

Spts. vini rect., ad % xx ; 640 



M. 



In ringworm, after washing with hot water and soap and drying. (A. 
Smith.) 



15. Luiio Plumbi et Opv. : 

Be . Liq. plumbi subacetat. dil. , ) 
Tinct. opii, J 

Aquae, 

In acute inflammatory conditions. 



aa Jj ; 32 
ad Oj; 500 



M. 



16. R . /3-naphthol, gr. xv; 1 

Spts. sapo viridis, ^vj ; 25 

Alcoholis, £ jss ; 50 

Bals. peruv., gtt xxx ; 2 

Sulph. loti, 3ijss; 10 

In sycosis. (Kaposi.) 



M. 



17. &• Glycerole of starch, "I 

Oil of cade, J 

Green soap, 

Sig. In psoriasis. External use. 

18. Piffard's Substitute for Tar 

H • Ac. salicyl. , 

01. lavandulae, §ijss; 

01. citronellae, 3 SS 5 

01. pini sylvestris, % ij ; 

01. ricini, % jss ; 

In eczema capitis. 



aa 100 parts. 
5 " 



gr. x-xxx; 0.66-2 
10 

2 
64 

48 



M. 



M. 



19. & • Sodiihypophosphitis, ^ j ; 32, 

Glycerini, 3 SS ; 16 1 

Aquae, ^ viij 256 1 

For dermatitis venenata. (Morrow.) 



M. 



APPENDIX. 



577 



20. Sulphur Lotion : 

R Sulphuris loti, "] 
Alcohol., 
Etheris, \ 

Glycerini, 
Potass, carb , J 
Aq rosse, 

Used in acne. 

21. Thymol Lotion : 

R. Thymol, 1 

Liq. potassae, / 
Glycerini, 
Aq sambuci, 

For seborrhoea sicca capitis, 
the amount of thymol. 



3y 



;viij 



3j; 

fss; 
viij 



256 



M. 



16 
256 



M. 



Also for pruritus cutaneus, with double 



22. Tinctura Saponis Viridis : 

R. Sapo viridis, \ 
Alcohol., J 



Equal parts. 



M. 



23. Tmct. Saponis Co. of Heb 


•*a : 






R. 01. cadini, ^| 
Sapo viridis, > 
Alcoholis, J 
Filtra et adde 

Spts. lav an dulse, 


aa 


3ij; 


32 

8 


Stimulant in chronic eczema. 








24. Vleminckx's Solution : 








Be. Calcis vivse, 

Sulphur sublimat., 
Aq destillat., 






16 
32 
320 



M. 



M. 

Boil together with constant stirring until the mixture measures six 
fluidounces, then filter. 

Useful in scabies, psoriasis, and acne. 



25. R. Zinci oxidi, 
Ac. carbol., 
Aquse calcis, 
For dermatitis venenata. 



3j; 

Oj; 



16 
4 

500 



M. 



White.) 



1. Bassorln Paste 



R 



Basso rin, 
Dextrin, 
Glycerin, 
Water, 



c. Ointments. 



48 parts. 
25 '' 
10 " 
ad 100 " 



M. 



578 



APPENDIX. 



2. Bismuth Ointment: 

B. Bismuthi subnit., \ 
Kaolini, J 

Vaselini, 

For chloasma. (Unna.) 



Z jss ; 7 

3 V J ad Ij ss ; 30 



3. R . Ac borici, gr. x; 

Ac salicylici, gr. xv 

Ungt. aquae rosse, ^j ; 

For chromidrosis. (Van Harlingen.) 

4. Chrysarobin Ointment : 

R • Chrysarobin, 
Ac salicylici, 
Plasment vel, \ 
Adipis, J 

Used in psoriasis and ringworm 

5. R. Chrysarobin, "I 

Ichthyol, J 

Ac. salicyl, 
Ungt. simpl., 

Used in leprosy. (Unna.) 

6. Diachylon Ointment (Hebra) : 

Be . Olive oil, 3 xv 



1 

30 



gr. 1; 
gr. x ; 


3 


Ij; 


30 


aa gr. lxxv ; 


5 


gr. xxx ; 

liij; 


2 
100 



480! 



Litharge, giij, 3yj; 120 

Boil together to a good consistence and add 



Oil of lavender, 

7. Be Hydrarg ammon , \ 

Bismuthi subnit , J 
Ungt aq. rosse, 

Used in lentigo. (Hardaway. ) 

8. B- Hydrarg. ammon., 

Hydrarg. chlor mitis, 
Vaselini, 



3y; 

aa 5j; 



3j; 



4j 
30 1 



5-10 

10-20 

100 



M. 



M. 



M. 



M. 



M. 



M. 



Used in seborrhoea sicca capitis and pityriasis capitis. (Bronson. 



9. R. Hydrarg. bichlor., gr. j-v ; 1-5 

Ac. carbol., gr. xx ; 20 

Ungt. zinci oxid., ^j ; 500 

Used in lichen ruber. (Unna.) 



M. 



APPENDIX. 



579 



10. R. Ac salicylic!, gr. x 

Ungt. hydrarg. ox. rub., gj ; 



Ungt. aquae rosse, 
For blepharitis. (Webster. ) 

11. Be. Hydrarg. protiodid., 
Hydrarg. ammon., 
Ungt. simplicis, 

Used in acne. (Duhring.) 



5^J5 



gr. v-xv ; 
gr. x-xxx; 



66 



12. R. Hydrarg. sulph. rubri, gr. xv ; 

Sulph. sublimat., ^vj ; 

Adipis, ad ^iij ; 

01. bergamot., q. s. 

Used in sycosis. (Behrend.) 



4 

24 



0.33-1 

0.66-2 

32 



1 
24 
75 



M. 



M. 



M. 



aa 



3J ss ; 



50 
10 



13. R. Ungt. diachyli (Hebra),| 

Ungt. zinci oxidi, J 

Ungt. hydrarg. ammon., 

Bismuth, subnitrat., gjss ; 5 1 M. 

In sycosis. (Robinson.) 

14. Lassar's Paste : 

R . Zinci oxidi, "I .. 

Amyli, < } aa 3ij; 

Vaselini, Z 1Y \ 

Asa protective application and as excipient for other drugs. 

15. Naphthol Ointment : 



32 



M. 



R. /5-naphthol, 
Cretse preparat., 
Sapo viridis, 
Adipis, ad 

Used in scabies. (Kaposi.) 

16. Naphthol Ointment: 

R. 5-naphthol, 
Sulph. precip , 
Vaselini, ) 

Sapo viridis, / 

Used in acne. (Lassar.) 

17. R . Ac. salicylici, 

Sulphur, precip., 

Lanolini, 

Vaselini, 

For chromophytosis. (Brocq.) 






15i 

10 

50 

ioo! 



M. 



10 parts. 
50 " 



aa 25 



2-3 parts. 
10-15 " 
70 ". 
18 " 



M. 



M. 



580 



APPENDIX, 



18. R. Sulphur., 

Potass, carb., 
Adip. benzoat , 
01. chamomilis, 

Used in scabies. (Wilson. ) 
19 Helmerich's Ointment 



3j; 
3y; 

Ev; 

3ss; 



32 

8| 
160, 

2 



R. Sulphur, 
Potass, carb., 




|ij ; 


30 
15 


Adipis, 




3 viij ; 


120 


Used in scabies. 








20. Wilkinson's Ointment 


(Hebra J : 






R. Sulphuris, \ 
01 cadini, J 


aa 


!§ss 


20 


Sapo viridis, \ 
Adipis, J 
Cretse preparat. , 


aa 


3J; 

3yss; 


40 
10 


Used in scabies. 








21. R . 01. fagi, \ 
Flor sulph., j 
Pulv. cretse alb , 


aa 


3J; 


10 
5 


Adipis, [ 
Sapo viridis, J 


aa 


3v; 


20 


In sycosis. (H. Hebra. 








22. ft. 01 cadini, \ 
Zinci oxidi, J 


aa 


.^ss-j; 


2-4 


Ungt. aqua? rosse, 




3j; 


30 


In chronic eczema. 








23. ft. Glycerini, 

Gum tragacanth , 
Sulph sublimat., 
Potass, carbonat., 




200 

5 

100 

35 


parts. 
n 

a 
tt 


01. lavandulse, ] 









01. menth. pip , 
01 caryophylli, 



I" 



01. cinnamomi, J 
Used in scabies. (Bourguignon.) 

24. ft. Zinc oxide, \ 
Zinc carbonate, j 
Hose ointment, 

In sycosis after shaving. (T. Fox.) 



aa 
ad 



aa 



3J; 



1.5 



4 
32 



M. 



M. 



M. 



M. 



M. 



M. 



M. 



APPENDIX. 






581 


d. Miscellaneous. 






1. Anti-pruritic Poxoder : 








I£. Camphori, 
Zinci oxidi, 
Amyli, 


3ss; 


3 
15 
30j 


M. 


2. Corn Remedy : 




(Bulkley.) 




££. Ac. salicylici, 

Ext. cannabis indicse, 
Alcoholis, 
^Etheris, 
Collodion flex. , 


gr. xv ; 
gr. viij 

mixxN 


1 

1 

2 

r; 5 


5 

66 


M. 


Apply with brush three times a 
ick out corn. (Vigier.) 


day for one 


week. Soak feet and 


3. Epilating Stick : 








1$. Cerse flavae, 

Laccse in tabulis, 
Picis burgundicse, 
Gumrai damar., 




12 
16 
40 

48 




M. 


Make in stick one-half to one inch 
Bulkley. ) 


in diameter 


and two i 


aches long. 


4. Glycerin Jelly: 








1£. Gelatini, 
Glycerini, 
Aquse, 


gr. xxv ; 1 
gr. ccxxv; 15 
3iv; 16 


66 


M. 






5. Glycerole of Subacetate of Lead : 

Be. Plumbi acetat. gr. exx ; 8 

Plumbi oxidi, gr. lxxxiv ; 6 

Glycerini, §j ; 32J M. 

Digest the lead in the glycerin heated to 300° F. in an oil bath for 
half an hour, constantly stirring. Filter in a chamber heated to 300° F. 

Dilute from three to seven times with water and glycerin, and use as 
astringent and sedative in chronic eczema. (Squire.) 



INDEX. 



A BSCESS, 50 

ii. Acantholysis bullosa, 206 
Acanthosis nigricans, 51 
Achorion Schoenleinii, 241 
Achroma, 312 
Acid, oleic, 42 

oxynaphthoic, 44 
Acne, 52 

adenoid, 331 

albida, 344 

artificialis, 66 

arthritique, 67 

atrophica, 66 

atrophique, 67 

cachecticorum, 66 

cornee, 427 

erythematosa, 435 

fluente, 464 

follicularis, 120 

frontalis, 67 

indurata, 54 

keloid, 150 

lupoid, 67 

mentagra, 473 

miliare scrofuleuse, 67 

necrotica, 67 

pilaris, 67 

punctata, 52, 120 

punctuee, 120 

rodens, 67 

rosacea, 435 

rosee, 435 

scrofulosorum, 66 

sebacea, 464 

cornea, 296, 426 

sebacee, 464 

cornee, 296, 426 

simplex, 52 

sycosis, 473 

syphilitica, 493 



Acne, ulcereuse, 67 

varioliformis, 67, 345 

vulgaris, 52 
Acrochordon, 68, 251 
Acrodynia, 68 
Acromegaly, 69 
Actinomycosis, 69 
Addison's keloid, 349 
Adeno-carcinoma, 69 
Adenoma, 69 
Adenotrichie, 473 
Adeps lanae, 42 
Agnine, 42 
Ainhum, 70 
Airol, 42 
Albinism, 312 

Aleppo boil, bouton, or evil, 70 
Algidite progressive, 454 
Algor progressivus, 454 
Alopecia, 71 

adnata, 71 

areata, 79 

circumscripta, 79 

follicularis, 79 

furfuracea, 75 

pityrodes, 75 

prematura idiopathica, 72 
symptomatica, 75 

senilis, 71 

syphilitica, 77 
Alopecie cicatricielle innominee, 

252 
Alphos, 412 
Alumnol, 42 
Anaesthesia, 85 
Anatomical tubercle, 542 
Angio -keratoma, 85 
Angioma, 87, 358 

cavernosum, 359 

pigmentosum et atrophicum, 94 



584 



INDEX. 



Angioma serpiginosum, 87 

Angiomyoma, 355 

Angioses, 87 

Anhidrosis, 88 

Anonychia, 88 

Anthrarobin, 43 

Anthrax, 104, 432 

Area celsi, 79 

Area occidentalis diffluens, 79 

Argyria, 88 

Aristol, 43 

Arrectores pilorum, 22 

Asiatic pills, 572 

Asteatosis, 88 

Atheroma, 462 

Atrophia cutis, 93 

pilorum propria, 89 

unguium, 93 
Atrophoderma, 93 

albidum, 96 

idiopathica diffusa, 96 

pigmentosum, 94 

senilis, 97 

striatum et maculatum, 97 
Aussatz, 305 

BAD disorder, 483 
Baker's itch, 188 
Baldness, 71 

circumscribed, 79 
Baelzer's disease, 99 
Barbadoes leg, 200 

glandular disease of, 200 
Barbers' itch, 473, 531 
Bartfinne, 473 

parasitische, 531 
Bartflechte ; 473 
Bassorin, 41, 577 
Baths, 569 
Birth mark, 358 
Blackheads, 120 
Blasenausschlag, 380 
Blutfleckenkrankheit, 427 
Blutschwar, 255 
Boil, 255 

Bougard's paste, 213 
Bouton, 52 
Brandrose, 99 
Brandschwar, 104 
Bricklayer's itch, 188 
Bromic acne. 147 



Bromidrosis, 99 
Bucnemia tropica, 201 
Bulla, the, 27 
Burning, 38 
Burns, 128 

flACOTROPHIA folliculorum, 

\J 299, 427 
Calculi, cutaneous, 344 
Callositas, 101, 299 
Callus, 101 
Calotte, the, 245 
Calvezza, 71 
Calvities, 71 
Cancer en cuirasse, 108 

epithelial, 207 

tubereux, 293 
Cancroide, 207 
Canities, 102 
Canquoin's paste, 573 
Caraate, 390 
Carbuncle, 104 
Carcinoma, 107 

lenticulare, 108 

melanodes, 108 

tuberosum, 108 
Carron oil, 575 
Causalgia, 109 
Chalastodermia, 156 
Chalazion, 344 
Chaleur du foie, 109 
Chancre, 483 
Chap, 109 
Charbon, 432 
Cheilitis glandularis, 109 
Cheiro-pompholyx, 399 
Chelis or cheloide, 293 
Chicken-pox, 555 
Chilblain, 129 
Chloasma, 109, 114 

uterinum, 110 
Chorioblastosis, 112 
Chorionitis, 456 
Chromidrosis, 112 
Chromophytosis, 114 
Cicatrix, the, 29 
Claret stain, 358 
Classification, 46 
Clastothrix, 89 
Clavus, 118 < 

syphiliticus, 119 



INDEX. 



585 



Clou, 255 
Cnidosis, 549 
Cochin-China leg, 200 
Cold sore, 263 
Collodion, 39 

Colloid degeneration of the skin, 
120 

milium. 120 
Comedo, 120 
Condyloma lata, 491 

acuminata, 557 
Congelatio, 129 

Connective tissue, subcutaneous, 16 
Cor, 118 
Corium, 16 
Corn, 118 
Cornu cutaneum, 124 

humanum, 124 
Cosme's paste, 572 
Coster's paint, 575 
Couperose, 435 
Creolin, 43 
Crust, the, 28 
Crusta lactea, 182 
Cute, 390 
Cutis anserina, 125 

pendula, 156 

tensa chronica, 456 
Cyanopathie cutanee, 112 
Cyanosis, 125 
Cyst, dermoid, 463 

sebaceous, 462 
Cysticercus cellulosae cutis, 125 
Cysto-adenoma, 126 

DACTYLITIS, 510 
Dandruff, 397, 465 
Dartre pustuleuse mentagre, 473 

erythemoide, 221 

rongeante, 332 

vive, 160 
Dartrous diathesis, 126 
Dasyma, 274 

Defluvium capillorum, 79 
Demodex folliculorum, 122 
Dermalgia, 126 
Dermatalgia, 126 
Dermatitis, 127 

ambustionis, 128 

bullosa, 206 

calorica, 128 



Dermatitis congelationis, 129 

contusiforme, 231 

epidemica, 130 

erythematosa, 221 

exfoliativa, 131 

neonatorum, 136 

fungoid, 352 

gangrenosa, 136 
infantum, 138 

glandularis erythematosa, 326 

herpetiformis, 139 

malignant papillary, 366 

medicamentosa, 145 

papillaris capillitii, 150 

papillomatosa capillitii, 150 

repens, 151 

traumatica, 152 

venenata, 152 
Dermatol, 43 
Dermatolysis, 156 
Derm ato mycosis favosa, 238 
Dermatomykosis tonsurans, 528 
Dermato-sclerosis, 456 
Dermatosis Kaposi, 94 
Desmoids, 251 
Diabetic eruptions, 157 
Diachylon ointment, 578 
Diagnosis, 23 
Distichiasis, 157 
Don'ts, 46 
Dracontiasis, 261 
Durillon, 101 
Dysidrosis, 399 

FCDERMOPTOS S, 345 
fj Ecthyma, 158 

infantile gangreneux, 138 
terebrant de l'enfance, 138 
Eczema, 160 

ani, 180 

aurium, 181 

barbae, 182 

capitis, 182 

crurum, 185 

exfoliativum, 131 

foliaceum, 131 

genitalium, 185 

hypertrophicum, 352 

infantile 193 

intertrigo, 186 

labiorum, 187 



586 



INDEX. 



Eczema mammarum, 187 

mammillarum, 187 

manuum, 188 

marginatum, 526 

narium, 190 

palpebrarum, 191 

pedum, 192 

seborrhoicum, 196, 464 

tuberosum, 352 

unguium, 192 

universale, 192 
Eiterpusteln, 158 
Ekzem, 160 
Elastic webbing, 41 
Elephantiasis, 200 

arabum, 201 

Jndica, 201 

Grsecorum, 305 
Emol, 43 
Emphysema, 205 
Endurcissement athrepsique, 454 
Ephelides, 303 
Ephidrosis, 272 

cruenta, 262 

tincta, 112 
Epidermis, 13 
Epidermolysis, 206 
Epilating stick, 581 
Epithelialkrebs, 207 
Epitheliom kystique benin, 214 
Epithelioma, 36, 207 

adenoides cysticum, 214 

contagiosum, 345 

multiple benign cystic, 214 
Epitheliomatose eczamatoide de la 
mamelle, 366 

pigmentaire, 94 
Equinia, 214 
Erbgrind, 238 
Eruptions, color of, 36 

configuration of, 30 

feigned, 248 

location of, 29 

ringed, 31 
Erysipelas, 215 

suffusum, 221 
Erysipeloid, 220 
Erythanthema, 221 
Erythema, 221 

caloricum, 222 

elevatum diutinum, 234 



Erythema exudativum, 227 

fugax, 224 

gangrenosum, 234 

hypersemicum, 221 

induratum, 235 

intertrigo, 222 

iris, 228, 230 

lseve, 224 

multiforme, 34, 227 

neonatorum, 225 

nodosum, 231 

paratrimma, 224 

pernio, 129, 222 

roseola, 224 

scarlatiniforme, 225 

simplex, 222 

traumaticum, 222 

urticans, 224 
Erytheme centrifuge, 326 

indure des scrofuleux, 235 

noueux, 231 

papuleux desquamatif, 391 
Erythrasma, 235 
Erythrodermie exfoliante, 131 
Erythromelalgia, 237 
Esthiomene, 237, 332 
Europhene, 43 
Exanthemata, 237 
Excoriation, the, 28 

T^AKCY, 214 
I Favus, 238 
Feusacre, 215 
Feuergiirtel, 564 
Feuermal, 358 
Fever blister, 263 
Fibroma, 249 

fungoides, 352 

lipomatodes, 559 

molluscum, 249 

pendulum, 249 
Fibromyoma, 354 
Fikosis, 473 
Filaria sanguinis hominis, 204 

medinensis, 261 
Finnen, 52 

Fischschuppenausschlag, 282 
Fish-skin disease, 282 
Fissure, 28 
Flea bites, 252 
Fleckenmal, 356 






INDEX 



587 



Flechte, fressende, 332 

kleien, 114 

nassende. 160 

scheerende, 525, 528 
Flesh worms, 120 
Fluxus sebaceus, 464 
Folliculitis, 252 

barbae, 252, 473 

decalvans, 252 

pilorum, 473 
Foot, tubercular disease of, 254 
Fragilitas crinium, 89 
Frambcesia, 150, 563 
Freckles, 303 
Frieselausscblag, 342 
Frost bite, 129 
Fuchsine, 44 

Fungous foot of India, 254 
Furunculi atonici, 158 
Furunculus, 255 

H ALE, 446 

IT Gallacetophenone, 44 
Gangrene, symmetrical, 137 
Gangrenes multiples cachectiques, 

138 
Gefassmal, 358 
Gelatin preparations, 40 
Geromorphisme cutane, 260 
Glanders, 214 
Glossy skin, 97 
Glycerine jelly, 581 
Glvcerole of subacetate of lead, 

581 
Gneis, 464 

Gommes scrofuleuses, 461 
Goose-flesh, 125 
Granuloma, 260 

fungoides, 352 
Grayness, 102 
Grubs, 120 
Grutum, 344 

Guinea-worm disease, 261 
Gumma, 500 

scrofulous, 461 
Giirtelkrankheit, 564 
Gutta rosacea, seu rosea, 435 

HAAKMENSCHEN, 275 
Hsematidrosis, 262 
Hsemidrosis, 262 



Hsemorrhoea petechialis, 427 
Hair, anatomy of, 18 

blanching of, 102 

discolorations of, 262 

ringed, 103 

superfluous, 274 
Hand and foot disease, 386 
Harlequin foetus, 284 
Hauthorn, 124 
Hautrose, 215 
Hautrothe, 221 
Hautsclereme, 456 
Hautschmerz, 126 
Hautwiirmer, 120 
Heat eruption, 160 
Helmerich's ointment, 580 
Hemiatrophia facialis progressiva, 

97 _ 
Hernia carnosa, 201 
Herpes circine parasitaire, 528 

circinatus, 139, 267, 525, 528 
bullosus, 267 

esthiomenos, 332 

facialis, 263 

febrilis, 263 

gestationis, 139, 268 

iris, 230 

labialis, 263 

phlyctaenoides, 139 

preputialis, 265 

progenitalis, 265 

pustulosus mentagra, 473 

squamosus, 528 

tonsurans, 528 
barbae, 531 
maculosus, 391 

tonsurante, 528 

zoster. 564 
Herpetide,' 268 

exfoliative, 131 
Hide-bound disease, 456 
Hidrocystoma, 268 
Hirsuties, 274 
History of case, 37 
Hitzblatterchen, 160 
Hives, 549 
Homines pilosi, 275 
Horn, cutaneous, 124 
Hiihnerauge, 118 
Hutchinson's teeth, 509 
Hyalorn der Haut, 120 



588 



INDEX. 



Hydradenomes eruptifs, 214 
Hydroa, 139, 270 

bulleux, 139 

febrilis, 263 

puerorum, 270 

vacciniforme, 270 
Hydro-adenitis, 256 
Hydroxylamine, 44 
Hyperesthesia, 271 
Hyperidrosis, 272 

oleosa, 469 
Hyperkeratosis follicularis, 299 

excentrica, 274, 401 
Hypertrichosis, 274 

TCHTHYOL, 44 

1 Ichthyose anserine des scrofu- 

leux, 299 
Ichthyosis, 282 
Ichthyosis follicularis, 296, 299, 426 

palmaris et plantaris, 299 

sebacea, 464 

sebacea cornea, 426 
Idrosis, 272 
Ignis sacer, 564 
Impetigo, 286 

contagiosa, 287 

herpetiformis, 139, 292 

parasitica, 287 

simplex, 286 
Induratio telse cellulosse, 454 
Inflammatory fungoid neoplasm, 

352 
Initial lesion of syphilis, 483 
Intertrigo, 222 
Iodic acne, 6Q, 148 
Ionthus, 52 
Itch, 446 

bricklayers', 188 

grocers', 188 

washerwoman's, 188 

TUCKBLATTEBN, 403 

KAHLHEIT, 71 
Kelis, 293 
Keloid, 293 

of Addison, 349 
of Alibert, 293 
Keratoma follicularis, 284 



Keratoma palmare et plantare 

hereditarium, 299 
Keratosis epidermica, 284 

diffusa, 284 

follicularis, 296, 426 

intrauterine, 284 

palmaris et plantaris, 299 

pilaris, 299 
Kerion, 301, 529 

Celsi, 301 
Knollenkrebs, 293 
Koltun, 398 
Kratze, 446 
Kraurosis vulvae, 302 
Krause's corpuscles, 18 
Kreisfleckige Kahlheit, 79 
Kupferfmne, 435 
Kupferrose, 435 
Kupfrigesgesicht, 435 
Kummerfeld's lotion, 575 

T ANOLIN, 42 
-Li Lassar's paste, 579 
Leberflecken, 109 
Leichdorn, 118 
Lentigo, 303 

maligna, 94 
Leontiasis, 305 
Lepothrix, 304 
Lepra, 305, 412 

alphos, 412 

arabum, 305 
Leprosy, 305 

Lombardian, 378 
Leucasmus, 312 
Leucoderma, 312 
Leucopathia, 312 

unguium, 315 
Leucoplakia, 316 
Leukaethiopes, 315 
Lichen circinatus, 466 

hypertrophicus, 319 

menti, 473 

obtusus, 319 

pilaris, 299 

planus, 36, 316 

ruber acuminatus, 321 
moniliformis, 319 

scrofulosorum, 324 

scrofulosus, 324 

simplex, 163 



INDEX. 



589 



Lichen spinulosum, 426 

tropicus, 342 

verrucosus, 319 
Lineae albican tes, 98 
Linsenflecke, 303 
Linsenmal, 356 
Liodermia essentialis cum melanosi, 

etc , 94 
Lipoma, 326 
Liquor anthracis, 44 

gutta perchae, 39 

picis alkalinus, 575 
Liver spot, 109 
Lotio alba, 576 

plumbi et opii, 576 
Lousiness, 372 
Lues, 483 
Lupoid acne, 331 
Lupus erytkematodes, 326 

erythematosus, 36, 326 

exedenes, 331 

exfoliativa, 332 

exulcerans, 332 

hypertrophicus, 333 

lymphaticus, 339 

miliaris, 331 

papillaire verruqueux, 542 

papillomatosis, 333 

sclereux, .542 

sebaceus, 326 

superficialis, 326 

tuberculosus, 332 

verrucosus, 333, 542 

vorax, 332 

vulgaris, 332 
Lustseuche, 483 
Lymphadenie cutanee, 352 
Lvmphadenoma, 315 
Lymphangiectasis, 339 
Lymph angiectodes, 339 
Lymphangioma, 339 

tuberosum multiplex, 341 
Lymphangio-myoma, 354 
Lymphatics, 17 

Lymphodermia perniciosa, 352 
Lymphorrhagica pachydermia, 339 

MACCHIE epatiche, 109 
Macule, the, 23 
Maculae caeruleae, 374 

et striae atrophica?, 98 



Madesis, 341 
Madura foot, 254 
Mai de los pintos, 390 

de la rosa, 378 
Mai roxo, 378 
Malleus, 214 
Malum venereum, 482 
Mamillaris maligna, 366 
Marden's paste, 572 
Mask, 109 
Masque, 109 
Measles. 348 

German, 442 
Meissner's corpuscles, 18 
Melanoderma, 110 
Melasma, 110 
Melanosarcoma, 443 
Melanosis lenticularis progressiva, 

94 
Melastearrhee, 112 
Melitagra, 182 
Mentagra, 473 
Microsporon anomaeon, 393 

furfur, 115 

minutissimnm, 236 
Middlesex Hospital paste, 574 
Miliaria, 342 
Miliary fever, 344 
Milium, 344 
Milk crust, 182 
Mitesser, 120 
Mole, pigmentary, 356 
Molluscum cholesterique, 559 

contagiosum, 345 

epitheliale, 345 

fibrosum, 249 

pendulum, 249 

sebaceum. 345 

sessile, 345 

simplex, 249 

verrucosus, 345 
Morbilli, 348 
Morbus elephas, 201 

gallicus, 483 

hispanicus, 483 

indicus, 483 

italicus, 483 

maculosus Werlhoffii, 428 

neapolitanus, 483 

pediculare 372 
Morphcea, 349 



26 



590 



INDEX. 



Morpion, 374 
Morvan's disease, 352 
Morve, 214 
Moth patch, 109 
Mother's mark, 356 
Mucous patch, 491 
Muslin, plaster, 40 

salve, 40 
Myasis externa dermatosa, 352 
Mycetoma, 254 
Mycosis frarnboesiodes, 150 
Mycosis fungoides, 352 

microsporina, 114 
Myoma, 354 
Myronin, 42, 44 
Myxoedema, 355 



NiEVUS araneus, 523 
flammeus, 359 

lipomatodes, 356 

pigmentosus, 356 

pilosus, 356 

sanguineous, 358 

simplex, 358 

spilus, 356 

tuberosus, 359 

unius lateris, 358 

vascularis, 358 

venous 359 

verrucosus, 284, 356 
Nails, anatomy of, 21 

atrophy of, 93 
Narbenkeloid, 293 
Neoplasm, inflammatorv fungoid, 

352 
Nerven nsevus, 284, 361 
Nerves, 17 
Nesselausschlag, 549 
Nesselsuch, 549 
Nettle rash, 549 
Neuralgia of the skin, 126 
Neuroma cutis, 362 
Nodosites non-erythemateuses des 

arthritiques, 362 
Nodules, ephemeral cutaneous, 
362 

subcutaneous rheumatismal, 
362 
Nodulus laqueatus, 362 
Noli me tangere, 207, 332 



a^DEMA cutis, 363 
J neonatorum, 363 
(Esypus, 42 
Oleum chcenoceti, 42 

physeteris, 42 
Oligosteatoses, 364 
Onychatrophia, 93 
Onychauxis, 364 
Onychia, 365 
Onychitis, 365 
Onychogryphosis, 364 
Onychomycosis, 366, 532 
Ophiasis, 79 
Osmidrosis, 99 
Osteosis cutis, 366 



DACHYDEEMATOCELE, 156 
1 Pachydermia, 201 
Pacinian corpuscles, 18 
Paget's disease of the nipple, 366 
Pain, 38 

Panaris nerveux, 369 
Panaritium, 371 
Panne hepatique, 109 
Panniculus adiposus, 17 
Papillar Geschwiilste der Haut, 
beerschwamahnliche multiple, 
352 
Papilloma, 369 

area elevatum, 369 

neuropathic, 284 

neuroticum, 284 
Papule, the, 25 
Parangi, 563 
Parakeratosis scutalaris, 370 

variegata, 370 
Parasitic diseases, 370 
Paronychia, 371 
Pastes, 40 

Patients, examination of, 38 
Paxton's disease, 424 
Pedicularia, 372 
Pediculosis, 372 

capitis, 372 

pubis, 374 

vestimentorum, 373 
Pelade, 79 

Peliosis rheumatica, 429 
Pellagra, 378 
Pemfigo, 380 



INDEX. 



591 



Pemphigus, 380 

contagiosis, 382 

foliaceus, 382 

gangrsenosus, 138 
, neonatorum, 382 

pruriginosus, 139, 382 

vegetans, 382 

vulgaris, 380 
Pencils, paste, 41 

salve, 41 
Perifolliculitis suppurees et con- 
glomerates en placards, 387 
Perisarcoma, 433 
Perleche, 388 
Pernio, 129 
Phagmesis, 389 
Phlegmasia malabaraca, 201 
Phlyzacia agria, 158 
Phthiriasis, 372 
Phyto-alopecia, 79 
Pian, 563 

ruboide, 150 
Piebald-skin, 312 
Piedra, 389 
Pigment, 15 
Pigmentflecken, 109 
Pigmentmal, 356 
Pimple, 52 
Pinta, 390 
Pityriasis, 464 

capitis, 397, 468 

circine et margin e, 391 

maculata et circinata, 391 

nigricans, 112 

parasitaire, 114 

pilaris, 299 

rosea, 35, 391 

rubra, 131, 132 
pilaris, 394 

simplex, 397 

tabescentium, 398 

versicolor, 114 
Plasment, 41 
Plica Polonica, 398 
Plique polonaise, 398 
Podelcoma, 254 
Poils accidentels, 274 
Poliosis, 102 
Poliotes, 102 
Poliothrix, 102 
Polyidrosis, 272 



i Polytrichia, 274 
; Pompholyx, 268, 380, 399 
Porcellanfriesel, 549 
Porrigo, 182, 238 

contagiosa, 287 

decalvans, 79 

favosa, 238 

furfurans, 528 

lavalis, 238 

lupinosa, 238 

scutulata, 238 
Porrigophyta, 238 
Porokeratosis. 401 
Portwine mark, 358 
Pox, 483 
Prairie itch, 402 
Prickly heat, 342 
Pronunciation, scheme of, 50 
Prurigo, 403 
Pruritus cutaneus, 406 

hiemalis, 407 

oestivalis, 407 

senilis, 407 
Pseudo-erysipelas, 411 

-leucaemia cutis, 411 
Psora, 412 
Psoriasis, 33, 412 

buccalis, 316 
Psorospermose folliculaire vege- 

tante, 296 
Psorospermosis follicularis cutis, 

426 
Pterygium, 427 
Purpura, 427 
Pustula maligna, 432 
Pustule, the, 26 

QUINQUAUD'S disease, 253 
Quirica, 390 

RAYNAUD'S disease, 137 
Ked gum, 343, 433 
Resorbin, 42 
Resorcin, 45 
Eete Malpighii, 15 
Rheumatism of skin, 126 
Rheumatokelis, 433 
Pvhinophyma, 437 
Rhinoscleroma, 433 
Rhus- poisoning, 152 
Ringed eruptions, 31 



592 



INDEX. 



Ringskurv, 528 
Ringworm, 525 

crusted, 238 

honeycomb, 238 

of the beard, 531 

of the body, 525 

of the nails, 532 

of the scalp, 528 

Polish, 398 
Risipola lombarda, 378 
Hitter's disease, 136 
Rodent ulcer, 209 
Rogna grossa, 158 
Rosacea, 435 
Rose, la, 215 
Rosee, 435 
Rose rash, 221 
Roseola, 224 

syphilitica, 487 

pityriaca, 391 
Rotheln. 442 
Rothlauf, 215 
Rotz, 214 
Rubeola, 348, 442 
Run around, 371 
Rupia, 499 

escharotica, 138 

CJT. ANTHONY'S fire, 215 
kJ Salol, 45 
Salt rheum, 160 
Salzfluss, 160 
Sarcocele, Egyptian, 201 
Sarcoma, 443 

cutis multiple, 352 
Sarcomatosis generalis, 352 
Satyriasis, 305 
Sauriasis, 282 
Sauroderma, 427 
Scabies, 446 
Scale, the, 28 
Scall or scald, 160, 182 
Scald head, 182, 238 
Scalp, hygiene of, 73 
Scar, hypertrophied, 295 

keloidal 295 
Scarlatina, 454 
Schmeerfluss, 464 
Schuppenflechte, 412 
Scissura pilorum, 89 
Sclerem der neugeboren, 454 



Sclerema adultorum, 456 

neonatorum, 454 
Sclereme des adults, 456 
Scleriasis, 456 
Sclerodactylie, 458 
Scleroderma, 456 

circumscribed, 349 
neonatorum, 454 
Sclerodermic, 456 
Scleroma adultorum, 456 
Sclerostenosis, 456 
Scrofulide boutonneuse benigne, 
403 
erythemateuse, 326 
tuberculeuse, 332 
Scrofuloderma, 460 
ulcerative, 352 
verrucosum, 542 
Scurvy, land, 428 
Sebaceous glands, anatomy of, 2 1 
Seborrhagia, 464 
Seborrhea, 34, 464 
congestiva, 326 
nigricans, 112 
Seborrheal eczema, 196 
Shingles, 564 
Sicosi parasitaria, 531 
Siderosis, 472 

Skin, anatomy and physiology of, 
13 
bloodvessels of, 17 
lesions of, 23 
muscles of, 22 
neuralgia of, 126 
Skin splints, 40 
cancer, 207 
Smallpox, 555 
Soaps, medicated, 41 
Sommersprosse, 303 
Spargosis, 201 
Spedalskhed, 305 
Sphaceloderma, 136 
Spider cancer, 523 
Spilosis poliosis, 102 
Spotted sickness, 390 
Startin's mixture, 571 
Stearrhcea, 464 

nigricans, 112 
Steatoma, 462 
Steatorrhea, 464 
Steiesol, 45 



INDEX. 



593 



Stigmata, 262 
Stonepock, 52 
Stratum corneum, 15 

mucosum, 15 
Strife et maculae atrophica?, 97 
Strophulus, 343 

albidus, 344 

prurigineux, 403 
Sudamina, 342 
Sudatoria, 272 
Sudor urinosus, 548 
Summer eruption 270 
Sweat glands, anatomy of, 22 

blue, 112. 

green, 114 

red, 114 

yellow, 114 
Sweating, excessive, 272 
Sycosis, 473 

barbae, 473 

capillitii, 150 

framboesia. 150 

menti, 473 

non parasitica, 473 

parasitaria, 531 

parasitica, 531 
Syphilis, 32, 482 

hereditary, 503 
Syringocystadenoma, 214 
Syringomyelia, 521 



TACHE de feu, 358 
hepatique, 109 
ombrees, 374 
vasculaire, 358 

Tactile corpuscles, 18 

Tanne, 120 

Tar, 45 

acne, 66 

Tattoo, 522 

Teigne du pauvre, 238 
faveuse, 238 
pelade, 79 
tondante, 528 
tonsurante, 528 

Telangiectasis, 523 

Tetter, 160 

Therapeutic notes, 39 

Thilanin, 45 

Thiol, 45 



Tinctura saponis viridis, 577 
Tinea amiantacea, 464 

asbestina, 464 

barbae, 531 

circinata, 525 

decalvans, 79 

favosa, 238 

ficosa, 238 

imbricata, 527 

kerion, 301 

lupinosa ; 238 

maligna, 238 

nodosa, 389, 524 

sycosis, 531 

tondens, 528 

tonsurans, 528 

vera, 238 

versicolor, 114 
Tinna, 390^ 
Traumatacin, 39 
Trichauxis, 274 
Trichiasis, 524 
Trichoclasia, 89 
Trichoma, 398 
Trichomycosis nodosa, 389 
Trichomykosis capillitii, 301 

favosa, 238 
Trichonosis cana, 102 

discolor 102 

poliosis, 102 
Trichophytosis, 31, 525 

barbae, 531 

capitis, 528 

corporis, 525 

unguium, 532 
Trichophytie circinee, 525 

sycosique, 531 
Trichophyton tonsurans, 533 
Trichoptilosis, 89 
Trichorrhexis nodosa, 89 
Trichosis hirsuties, 274 

plica, 398 

poliosis, 102 
Tropical big leg, 201 
Tubercle, the, 25 

anatomical, 542 
Tuberculum sebaceum, 344 
Tuberculosis cutis, 542 

verrucosa cutis, 542 
Tumenol, 46 
Tumor, the, 27 



594 



INDEX. 



Tumor multiple fungoid papilloma- 
tous, 352 
Tylorna, 101 
Tylosis, 101 

linguae, 316 

palmse et plantse, 299 

TTLCEK, 28, 545 
U grave, 254 

perforating, of the foot, 386 

rodent, 209 

scrofulous, 460 

syphilitic, 502 

tropical phagedenic, 547 
Ulerythema, 326, 548 

ophryogenes, 300 

sycosiforme, 253 
Uridrosis 548 
Urticaire, 549 
Urticaria, 549 

sedematosa, 363 

pigmentosa, 553 

VACCINAL eruptions, 554 
V Varicella, 555 

gangrenosa, 138 
Variola, 555 
Varus, 52 

Vegetation dermique, 557 
Venereal wart, 557 
Verole, 483 
Verruca, 556 

necrogenica, 542 
Verrue, 556 

telangiectasique, 558 
Verruga endemic, 563 



Vesicle, the, 26 
Vienna paste, 573 
Vitiligo, 312 

capitis, 79 
Vitiligoidea, 559 
Vleminck's solution, 577 

WAKT, 556 
Warts, post-mortem, 542 
Warze, 556 

Washerwoman's itch, 188 
Washleather skin, 559 
Weichselzopf, 398 
Wen, 462 
Wheal, the, 27 
Whelk, 52 
Whitlow, 365, 371 
melanotic, 444 
Wildfire, 215 
Wundrose, 215 
Wilkinson's ointment, 580 

VANTHELASMA, 559 
JSl. Xanthelasmoidea, 553 
Xanthoma, 559 

diabeticorum, 563 
Xeroderma, 282 

pigmentosum, 94 
Xerodermic pilaire, 299 

VAWS, 563 



ZONA, 564 
Zoster, 564 



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GROSS (SAMUEL D.). A PRACTICAL TREATISE OX THE DIS- 
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LUCAS (CLEMENT). DISEASES OF THE URETHRA. Preparing. 
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LUDLOW (J. L.). A MANUAL OF EXAMINATIONS UPON 
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LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo 
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OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 

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THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- 



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POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
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POWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In 
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THE COMPEND OF ANATOMY. For use in the Dissecting 



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